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?

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. AcriKeywords: Health, Waiting lists, Booking service, CUP, Network, Centralization.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.Introduction 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 cant 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). [footnoteRef:1]In addition, important prioritization criteria have been created to manage waiting list problem, based on clinical criteria and professional judgment[footnoteRef:2][footnoteRef:3].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. [1: OECD Helath Policy Studies : Waiting Time Policies in the Health Sector - What Works?, Febbraio 2013] [2: Ministero 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] [3: DPCM 16.4.2002, Linee guida sui criteri di priorit per laccesso alle prestazioni diagnostiche e sui tempi massimi dattesa. ]

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.

Therefore, so as to identify the causes and implications of a so long waiting time in the Italian National Health Service (NHL), it is useful to distinguish among three classes of services: In-patient care, Out-patient medical care and outpatient diagnostics. The waiting time for in-patient care appears less critical than the one for out-patient services. According to OECD, this may be caused by a large number of factors. At first, the national and regional governmental tires agreed to prioritize some major interventions on the basis of clinical criteria, and this has brought about remarkable reductions of waiting time in some fields, such as oncology and cardio surgery. In the other hand, waiting time for out-patients results from:1) Weak incentives to clear waiting lists for National Health Service-funded organization2) Strong incentives for doctors to maintain private care as an attractive alternative3) Weak institutional and organizational control systemsWe have identified four different waiting lists according to the type of service. 1. Diagnostic tests (out patients)2. emergency hospitalization (in -patients)3. Cancer surgical operation (in- patients)4. No cancer surgical operation (out patients)For each type of service, we have identified an average waiting time which shows off the waiting time expressed in days in many Italian regions[footnoteRef:4][footnoteRef:5]: [4: OECD Helath Policy Studies : Waiting Time Policies in the Health Sector - What Works?, Febbraio 2013] [5: Prof. Gb.Grassi : Il problema delle liste dattesa.]

AssistanceWaiting Time

Diagnostic tests>1 Year

Emergency Hospitalization24 h

Cancer surgery60-90 days

No cancer surgery90-1year

TAB. 1 Waiting times

The results are stunning. The average waiting time for an X-ray ( a kind of diagnostic test) is almost more than a year, and for a simple operation, hernia for example, from 90 days to one year. Let us delve into this issue by analyzing some of its important aspects.

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

FIG.1 Italian National Health-Care System StructureOur research is aimed at Regional and Local level. As it is clear from Professor Nutis work[footnoteRef:6], the organizational aspect of the health system depends on the regions, with great regional variation. 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, with lack of cooperation between the different structures, under-utilization of some peripheral structures, inadequate facilities, and therefore large bid / ask problems. So as to tackle this problem, 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. However, 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. In addition, Italian Hospitals in general are considered as real companies and move on their own so as to achieve efficiency. 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. Of course, the reduced financial resources for the health facilities represent another important aspect that gets such health facilities to be underused , 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. [6: Prof.ssa Sabina Nuti :Italian Regional Healthcare Systems. How to manage them? 2012]

The national e -health information strategyThe socio-demographic evolution of the population, along with the need to balance the available resources and quality of care provided to population, are a stimulus to develop new ways of providing healthcare, which would, first of all, allow to track patient care pathways from the first interaction with the healthcare services. 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, such as clinical risk, diagnostic and therapeutic procedures with particular reference to their quality, allocated resources, used technologies and level of satisfaction perceived by the citizens. The implementation of a system of integrated healthcare services network gets a considerable importance, first of all at this very moment of a profound change and evolution of the National Healthcare System (SSN). It is characterized with an ever higher percentage of elderly people, 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, 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. These actions are essential to create a fair ground for the implementation of an eHealth Information Strategy at national level, with an unified governance. The main objective of this strategy is to ensure a harmonic, consistent and sustainable development of the national information systems , so as to support patient care and governance of NHS, with increasing interoperability levels. The implementation of the eHealth services is proceeding with considerable dynamism, through major projects at central level as well as through ongoing initiatives in almost all Italian Regions. These initiatives are mainly pertinent to the following areas, with significant priority of intervention: - health service access: integrated health services booking systems (CUP) that allow citizens to book health care services throughout the Country; - availability of patients clinical history: integrated electronic health recorded systems (EHR) for the management of all episodes of care for every citizen on individual basis; - innovation in primary care: establishment of general practitioners network, digitalization and - electronic transmission of prescriptions (ePrescriptions) and sickness certificates (on line transmission of sickness certificates); - structural and organizational redesign of healthcare services network through telemedicine.Now, after having analyzed the state of the art, we intend to concentrate our attention on the main organizational inefficiencies of the system that lead to the waiting list problem, that is the excessive autonomy of the ASLs and the current booking system.The excessive autonomy of ASLsTo fully understand the meaning and practical implications of the concept of self-organization of ASLs, we can schematically compare the current model of the National Health Service, introduced with the reform of 1993[footnoteRef:7] with the structure defined by L.833/78.[footnoteRef:8] [7: DECRETO LEGISLATIVO 7 dicembre 1993, n. 517, Riordino della disciplina in materia sanitaria] [8: LEGGE 23 dicembre 1978, n. 833, "Istituzione del servizio sanitario nazionale]

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. The USLs (Unit 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. This standardization of organizational models was the direct result of the desire to build a strong National Health Service, that is, a single institutional " container" within which to resolve the fragmentation and heterogeneity of health service inherited from the previous mutual societies . However, a growing gap between the formal structure and the real organization was simultaneously forming. Behind the apparent homogeneity of the formal organizational models, in fact, 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.Then, formal homogeneity but very substantial difference.With the changes introduced by Decree 517/93 and confirmed by Decree 229/99[footnoteRef:9] the legislator has recognized to the individual elements of the system (regions, ASLs and research institutes) the right and duty to define theirs own role, theirs development strategies, theirs organizational structure rather than deny the diversity under organizational models formally homogeneous. Assigning greater responsibility to the regions and establishing healthcare companies with strategic, organizational and capital autonomy, it is recognized the need to bridge the existing gap between formal structure and real structure. Organizational models are not predetermined and they can be configured according to the local needs. Within the institutional constraints fixed by the National Health Service, ASLs benefit of considerable autonomy in defining their organizational structure. Hence there is the possibility that, it exists different organizational models within the same region. [9: DECRETO LEGISLATIVO 19 giugno 1999, n. 229, "Norme per la razionalizzazione del Servizio sanitario nazionale]

The autonomy of A.S.L. includes organizational, accounting, administrative, patrimonial and technological management. 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).The accounting management involves the economic and financial area, while the administration management has the power to adopt administrative measures that imply public authority.Patrimonial area manage ASL assets, both through acts of acquisition and acts of divestiture and finally the technical management provides the procedures and methods of use of resources. The operational independence of A.S.L. has the power to determine independently the objectives of the action plan activities, the power to provide for the placement of human and financial resources and the power to verify the results.The underlying rationale for this new approach is that the ASL (according to the business principles) through the organizational autonomy and through private tools, should better respond to criteria of effectiveness and efficiency, respecting budgetary constraints through the balance between costs and revenues. If this approach has undoubtedly led to a number of advantages on the side of economy management, on the other hand, 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 particular objectives pursued by each local health authority ( efficiency in terms of cost, advanced structure, specialization).The end result is the weakness of overall governance and the complexity to develop an integrated system. In the absence of operational mechanisms and in the absence of an organizational culture that integrate the different structures, making them feel part of a single organization, constraining their choices and their behavior, that contrary are naturally led to autonomy, then it is difficult to imagine that only the formal adhesion to the same organization can guarantee by itself the pursuit of common goals.Thus, it appears the need to identify new organizational solutions designed to meet the growing exigency of integration between the different jurisdictions, institutions, structures and professions involved in the care pathway. These considerations suggest a focus on the model of the network welfare, as a complex organization in which a plurality of mutually independent and autonomous entities work in a coordinated way, offering integrated services and overcoming the existing boundaries fixed by the organizational structure.The debate on the contribution that the adoption of network models could provide to the health services , in terms of effectiveness and efficiency is substantial, both in the international arena (Pointer et al. 1994[footnoteRef:10], Hurley 1993[footnoteRef:11]) and in the national one (Cichetti, 2002[footnoteRef:12]; Lega , 2002[footnoteRef:13]). [10: POINTER D., ALEXANDER J., ZUCKERMAN H. (1994). Loosening the Gordian Knot of Governance in Integrated Health Care Delivery Systems. Frontiers of Health Services Management.] [11: HURLEY R. (1993). The Purchaser-Driven Reformation in Health Care:Alternative Approaches to Leveling Our Cathedrals, Frontiers of Health Services Management.] [12: CICHETTI A., CIPOLLONI E., DE LUCA A., MASCIA D., PAPINI P., RUGGERI M. (2005) Lanalisi dei network organizzativi nei sistemi sanitari: il caso della rete di emergenza della Regione Lazio, Atti del Convegno Nazionale dellAssociazione Italiana di Economia Sanitaria, Genova 10-11 novembre 2005] [13: LEGA F. (2002). Gruppi e reti aziendali in sanit , Milano, Egea]

In this perspective, the Information Technology, that supports the communication processes and that sustain decisions of individuals who carry out interdependent tasks can be a very useful tool.

The current booking serviceIn 2001, the Ministry of Health made the first national survey on waiting times for outpatient and in-patient services[footnoteRef:14]. In 2009 the Ministry of Health, has issued a document[footnoteRef:15] to help the regional hospitals organize their services. In particular, so as to facilitate booking, 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. [14: http://www.salute.gov.it/imgs/C_17_pubblicazioni_1577_allegato.pdf] [15: Ministero della Salute, Sistema CUP: Linee guida nazionali, 27 Ottobre 2009, Roma]

CUP is the service that guarantees you a specialist visit and diagnostic analyses booking. Every local ASL has its own CUP. To book or cancel outpatient within health services, citizens can either call the CUP call center or go to the CUP counter personally. As the local ASL is independent, the situation in terms of availability, coverage, and characteristics of the CUP is extremely heterogeneous. 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.

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. An integrated network doesnt exist.b) drop-out events[footnoteRef:16]: citizens sometimes don't go to the already booked appointment. In most of the cases, there are more absent patients than the present ones. [16: Mariotti G., Priorit cliniche in sanit, Franco Angeli, 2006]

c) multiple booking problems due to the lack of communication among various local CUPs, in fact, the existing CUP often operate on their own and through different channelse) 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 visitAll these problems create a very inefficient booking service contributing to the formation of long waiting time.

FIG.2 The current booking service system At the regional level, almost all the regions have adopted RECUP/SOVRACUP (Regional Unified center of reservation) that could allow patients to make booking in their region in various local structures, trying to introduce a mechanism of coordination, capable of covering all the available places for operations and visits.According to GianniFontana(cooperative social Capodarco), director of Re-Cup call center service, The RECUP was created to make life easier for citizens , to let them avoid unnecessary and often problematic shifts and long queuing in front of the counters. It tries to provide the concept of sharing among the local levels.[footnoteRef:17] [17: http://archive.forumpa.it/archivio/1000/1400/1420/1427/lorenzoni_fontana.htm]

The main problem regarding this particular kind of regional booking service is that so as to make it working properly, the ASL must share many of their agendas with RECUP/SOVRACUP. But some hospitals have transferred to RE-CUP only 2 per cent of their agendas, deciding to manage the remaining 98 per cent by themselves, and others hospitals dont do booking book at all.Anyone who does not provide his own agendas creates difficulties to other ASL, which have to meet all the demands of health services. All this at the citizens expenses as the RECUP/SOVRACUP is not able to offer them any available term. On the other hand, 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 everybodys collaboration. All this is at the citizens expenses as the RECUP/SOVRACUP is not able to offer them any available term.Thus, there is a large competition among the various local booking centers(CUP) and regional booking centers ( RE CUP). A CUP management in the ASL involves various directions : the Health , the Manager , the Information and in addition there is the Head of Service . So, maybe, some leaders keep in their mind the needs of their company much more rather than the regional system needs. Even where CUP regional / provincial system exist, in most cases , the CUP system does not have an adequate coverage in terms of performance actually booked services and performances. Regarding the deployment of regional / provincial CUP coverage at national level, the conditions are the following [footnoteRef:18]: [18: Micocci S, Trabucco A., Integrazione dei sistemi Cup: aspetti tecnologici e aspetti organizzativi, SALUTE E SOCIET, 2009]

8 Regions / Autonomous Provinces have a CUP regional / provincial system, 4 Regions / Autonomous Provinces claim to have ongoing projects or a CUP sub-regional/sub-provincial coverage 9 Regions / Autonomous Provinces describe to have neither implemented a system of booking at regional nor ongoing projects in this area.

FIG.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:

FIG.4 Linkage between CUP/RECUP and Regional/Local levelAs we have been able to see so far, the CUP exists in some regions at local level and in others, we can speak about co-presence of CUP at local and RECUP at regional level. The results in both cases are too poor. Thus, for the purposes of our assessment we have identified the general requirements and divided them between local and regional level.

REGIONAL LEVELLOCAL LEVELCOMMON

-Difficulty to make available the performance on the part of health care facilities.-No digital access-Inhomogeneous system

-Not pooled with cup

-Call center, the only way-No anticipated ticket payment

-For almost non digital access-Lack of communication among CUPS-No automatic cancellation mechanism

-Competition with cup-Competition with RECUP-No Preliminary analysis

- Insufficient Technologies -Competition among CUPS-Multiple booking

-Difficulties in data access-Overload Booking-Too independence

TAB. 2 General RequirementsThe Centralized Hospital Network ManagementThe 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. Our goal is to define what we call CHNM (Centralized Hospital Network Management) as a result of our work, that could be considered as a RECUP reorganization. In fact, 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, capable of producing excellent results in terms of reducing waiting lists. This new network is made up of elements, not necessarily associated with each other, but when combined they can create an innovative system ex novo, 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. For this purpose it is necessary to authenticate the user and make him recognizable by the software for each undertaken task. In this way, the system will be able to assign a single health service to a single user by preventing from multiple booking. The two key words of the CHNM are Centralized and Network.In fact, we believe that in such a context characterized by a huge amount of data, the most effective solution is centralization. Organizational design studies teach that with increasing complexity and amount of information to be managed, a possible solution for a suitable system is centralization.In the meanwhile, it is necessary to strengthen the network of existing CUP via the coordination carried out by IT. Combining centralization to an efficient network, the booking system management and waiting lists management will be much more effective and flexible.So, 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 .This is a fundamental point that allows to overcome the problem of information sharing. It is necessary to abandon the call center system, which is too slow and awkward. The intent is to create a CUP Unified database. The input must come from the institutions and they have to make the health facilities provide at least the 80% of their available services , so to leave the 20% for the emergency. 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. If this condition will be satisfied there would be a quantum leap in the level of service offering .- The establishment of a national award for the health facilities that share higher percentage of their service. In this way the already existed competition between CUP and RECUP would be converted in a positive view: in order to offer more services to the patients.-The creation of a complete interface between the CUP and the information system software as well as a connection between the two database systems ; thus we get a network system that sees the CHNM center to which all CUP business is connected. In this view the CHNM plays a key role in preventing from overbooking and multiple booking problems. The intent is to create a mechanism that would enable the patients to make just one single booking for a certain kind of visit. The booking will be managed by the CHNM database and it will be the only way to book.- In order to solve the problem of multiple booking and drop-out cases, the patients should be made more responsible by the immediate ticket payment. This could be a solution so as to limit the absenteeism.The information system contribution is important as it is able, in this context, to make a quite homogenous and standardizes organizational system of booking, breaking through the barriers between the regional level and the local one, and in this context they are considered as if they were a single level.

FIG.5 CHNM operative level

In order to solve the problem of inefficiency due to unnecessary visits, 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.- So, first of all, the concept: prevention is better than cure. According to what has emerged from the analysis of Doctor NDTV[footnoteRef:19], a channel of health information system, the idea of prevention can be realised only when people are informed how to protect themselves, and if infected how to take care of themselves and prevent from spreading the infection. Thus, we are talking about communication among people and among different provinces. In such a context the best tool to play this role is an Information System. [19: http://doctor.ndtv.com/section/ndtv/secid/0016/searchby/health_insurance/Health_Insurance.html]

- Secondly, it is the matter of the concept of a preliminary analysis. Through the CHNM platform, in fact, 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, thanks to telemedicine and e-visit:a) Telemedicineis the use oftelecommunicationandinformation technologiesin order to provideclinical health careat distance. 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. It is also used to save lives incritical careandemergency situations. European Commission attributes particular relevance to telemedicine. In particular, in the EU Communication (COM-2008-689) of November 4th 2008, named Telemedicine for the Benefit of Patients, Healthcare System and Society, several actions involving both European Union and Member States are described, aiming at promoting a greater integration of telemedicine services in clinical practice, removing major barriers to its full and effective implementation. In order to analyze home care services in a systematic way, actually those provided towards telemedicine, and to widespread the best practices arising from organizational, clinical, care supply, technological and/or economic point of view, in 2007, the Ministry of health stipulated an agreement with Emilia Romagna Region, subjected to subsequent renewals, concerning the establishment and execution of the National Observatory for evaluation and monitoring of eCare services. The following Regions take part in the Observatory: Tuscany, Liguria, Marche, Campania, as well as , from 2009, Veneto and Sicily Regions and , from 2011, Lombardy Region. With the aim of making a detailed picture of telemedicine services available in the Country, being also able to provide the information required at EU level towards the above mentioned EU Communication, and in agreement with the Coordination of the Health Committee of the Conference of Regions and Autonomous Provinces, the types of telemedicine projects and service investigated towards eCare Observatory have been expanded from homecare to all telemedicine services. 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, but also to monitor and measure the results achieved in the different Regions over the time. The Ministry of health is directly taking part in several initiatives in this area. Within the Consiglio Superiore di Sanit (Advisory body of the Italian Ministry of health) on February 24th 2011, a working group aimed at drafting national Guidelines for supporting the systematic use of telemedicine in SSN was set up. The working group is currently working on defining a strategic framework in which to place telemedicine services, models, processes and pathways for integration of telemedicine services in clinical practice, taxonomies, common classifications, as well as all the aspects related to legal and regulatory profiles along with economic and sustainability issues concerning telemedicine services.

b) According to Haya Rubin (Internal Medicine), 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 notrequire treatment beyond a prescription available online or diagnostic tests beyond blood tests. 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, and the doctor documents the visit online.

Telemedicine would become part of the CHNM as the first step of the reservation process. The user before proceeding to the booking would have the possibility to verify ex-ante the appropriateness of the health provision. This phase turns out to be a filter so as only reservations with an higher degree priority will access to the booking.Hence, it is possible to illustrate the Centralized Hospital Network Management as follow:

FIG.6 Centralized Hospital Network Management

At this point we can sum up our general components, which have been identified as possible solutions to our problem.

Regional Health sector standardizationMechanisms for only one reservation

Standardized computerized reservation systemMore responsible patients

CUP database softwareImmediate ticket payment

Provide at least 80% of servicesCentralization of reservations

National awards/feedback health facilitiese-visit/telemedicine/prevention

Service centralizationDigital online platform

TAB. 3 General Components

The Centralized Hospital Network Management results from the combination of all these elements, both technological (sms and e-mail sending, software, online platform) and organizational ones (standardization, centralization, 80% agendas provision).

Now we can compare the General Components and General Requirements:

GENERAL REQUIREMENTSGENERAL COMPONENTS

-Difficulties in making available the performance in a part of health care facilities.-Provide at least 80% of services-National awards/feedback health facilities

-Non digital access-Digital online platform

- Little homogenous system-Not pooled with CUP-Lack of communications among CUPs-Competition with CUP/RECUP-Competition among CUPs-Too much independence-Standardization of regional Health sector-Standardized computerized booking system-Unified CUP database - Centralized service- Regional and local = same level- Coordination mechanisms as rules, procedures through ex ante agreement

-Call center , the only way-Standardized and computerized booking system

-No anticipated ticket payment -Immediate ticket Payment

-No automatic cancellation mechanism -Mechanism for only one reservation

-No Preliminary analysis-e-visit/telemedicine/prevention

-Overload Booking- Drop-out events - Multiple bookings- Automatic E-mail/SMS sent by CHNM system some days before he appointment to remind the patients-Immediate Ticket Payment - One automatic booking mechanism through a unique centralized booking system

-Difficulties in data accessing-Digital online platform

An organizational point of view "An Organizational assessment of Interfirm Coordination Modes"[footnoteRef:20] by Anna Grandori turns out to be an important framework through which to analyze the network system we have proposed. In this work A.Grandori evaluates and examines various types of interdependencies among different organizations (through the use of variables such as the direction of resource flows, the interest of the parties and the information complexity), explaining on various mechanisms which can regulate them effectively. Adopting this eminent research tool, it is possible to frame the Centralized Hospital Network Management as a system characterized by pooled interdependence, 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, thereby configuring the minimal basic way in which two or more units are linked because of their belonging to the same organization. Specifically, 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. [20: A. Grandori, "An Organizational Assessment of Interfirm Coordination Modes", Organization Studies, 6/8, 1997;]

Moreover, the work by Anna Grandori examines the information complexity and the different interests of the parties, outlining numerous network configurations.Due to the similarities with our proposed system, in this paper we intend to refer to the configuration of foundation and more specifically of the bureaucratic model.We have already described the problem that affects ASL that is the competitiveness among them which creates many problems to the health services management. 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.In these terms, the relationship between the ASL represent a "foundation". 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, anyway, it is possible to agree ex ante over a set of procedures and resources. Besides, defining the bureaucratic model, Grandori suggests that even in the absence of conflicting interests, with increasing complexity and number of actors, the more effective coordination is the one of information codification and communication through written documents side by side with a set of rules, procedures and information systems, explaining that sometimes it is necessary to centralize the decisions making processes as well as procedures. Galbraith shares this opinion and shows in his work the coordinating mechanisms that organizations should adopt in conditions of increasing complexity and uncertainty[footnoteRef:21]. Talking about a stable organization with low uncertainty, but characterized with high complexity, Galbraith describes centralization as one of the best coordinating mechanisms to take. [21: Gailbraith J. Organization Design, Organizational Effectiveness Center and School, 1977 ]

Thus, in these terms, we can state that the network we have proposed , 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, integrated information system and that our proposal perfectly reflects previous research studies.ConclusionIn 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. 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. 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, without having to queue at the counter. Moreover, 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.But what are the advantages for the administration?At first, CHNM allows to streamline bookings , cancellations and shifts , optimizing the supply of such services. This results in shedding the precious places which are unnecessarily busy. Instead, booking at branches or call centers CUP a person is very likely to increase the number of busy places.Another advantage is the possibility of day-to- day 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 . So as to analyze the preferences means to understand them, and then to act accordingly. Surely, some structures need to be improved , but others are very good and have the same medical clinics in demand. Therefore, it is only the matter of making a targeted communication campaign so as to inform citizens about the same quality of other surgeries.The analysis of data related to booking is also useful for system studying in order to calibrate the issue. It is well known that the demands of many diagnostic tests are unnecessary or redundant . And this causes both a big waste to public health and less available performances/services for those who really need them. - 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. 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, could be one of hypothesis to take into account. Hence, for all these reasons the Centralized Hospital Network Management would allow to change the way to book health services and our project work, based on the concept of network, is ready to revolutionize the health care system and to make more efficient services, so as to avoid the long waiting lists, which are, unfortunately, a common problem of the Public Italian Health Care system.

References

ANNA GRANDORI, "An Organizational Assessment of Interfirm Coordination Modes", Organization Studies, 6/8, 1997;

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