IOP in Healh Care Services in Friuli Venezia Guilia · 1.3.1 Specific Objectives 11 1.3.2...

Prepared for the eGovernment Unit

DG Information Society and Media

European Commission

Case study prepared by Ralf Cimander and Herbert Kubicek (ifib, Germany), in co-operation with Andrea Soranzio from the Agenzia Regionale della Sanità del Friuli Venezia Giulia in Italy.

Good Practice Case

Regional integrated health

services for the continuity in the medical treatment in

Friuli Venezia Giulia

Case Study

05 May 2006

eGovernment Unit DG Information Society and Media

European Commission

Table of contents

1. Regional integrated health services for the continuity in the medical treatment in Friuli Venezia Giulia 2 1.1 Case Summary 2 1.2 Problem addressed 4 1.2.1 Specific Problem 4 1.2.2 General Background 8 1.2.3 Policy context and strategy 9 1.3 Solution 11 1.3.1 Specific Objectives 11 1.3.2 Implementation 12

- Basic components 12 - Workflow description 15

1.4 Features making it a candidate for good practice exchange 17 1.4.1 Impact 17 1.4.2 Relevance of the case for other administrations that could learn from the experience 18 1.4.3 Transferability 19 1.5 Results 22 1.6 Learning points and conclusions 24 1.7 References and links 26

Annex 1: Assessment Questionnaire for the MODINIS Case Descriptions 27

GP Case: Health services in F.Venezia G. – Italy 05-2006, vs. 1.0 1

1. Regional integrated health services for the continuity in the medical treatment in Friuli Venezia Giulia

1.1 Case Summary

The overall objective of the SISRCR (Regional integrated health services for the continuity in the medical treatment) in Friuli Venezia Giulia is creating an integrated system for the Regional Agency for Health and the Agencies for Health Services of the Region. Back-office and front-end systems allow for managing and distributing health services to the citizen and to specialised consumers (doctors, health operators) thanks to:

− a system of portals, one for each agency and a joint one − a call centre service for a constant access to the services − a smart card system to predispose and distribute the pharmaceutical prescriptions and the

medical authorisations.

Hence the project aims at supplying the citizens with a complete services system, which is focused first of all on the de-localisation of the access and information points in order to avoid useless accesses for the gathering of medical reports and information. The objective is not reducing the expenses through the decrease of the offered resources, but rather the rationalisation of their use.

The project has already activated seven portals, one for each territorial medical authority and one operating as a single access point to the eGovernment services of the Regional Health system. The Call Centre guarantees a constant covering of the access to health services, even without any Internet connection; whereas the smart card system uses the 'card of services'. That card has been created to allow regional citizens to buy discounted petrol, due to low price petrol in Slovenia. Now it is also used to access health services. More, there are two types of cards: for citizen (card of services) and for health operators. Each portal includes an Internet and an Intranet eGovernment area, whereby the latter is used by the Doctors of General medicine and Paediatric to prescribe medicines and health services.

Beyond the registration system of the portal, the system adopts the smart card as a second level of security. The smart cart access system: the patient card for patient identification and authorisation to access clinical information (folders); the health professionals card to operate in the portal system, retrieve information, make drug and treatment prescriptions and forward them digitally to the regional call-centre.

The pharmacies are entitled to manage the prescriptions drown up by the doctors of general medicine and help the citizens to book the medical visit that will then be booked at the CUP (Italian centres for the reservation of the medical visits) by the doctors or by the pharmacies through the portal. During the booking the citizen will be given the information about all available structures and services.

In terms of interoperability, the specific requirement was it to achieve IOP between different stages of a supply chain, i.e. between the independent public hospitals, the Local Health Administration, and the Regional Health Administration. In addition, IOP between the different channels offered in order to access or apply for information had to be achieved, in particular important is the access of the system by the General Practitioners which could be seen as the main stakeholders relevant for the diffusion of the system use; but also the integration of the call-centre and the local contact points (e.g. hospitals, health agencies) was paramount. A special feature is the introduction of a central database containing the medical records of patients instead


of storing them decentralised at the various General Practitioners, the hospitals and other with medical treatment concerned authorities/agencies. This in particular enables IOP between different health services referring to the same patient. Besides improving the medical treatment, this system assists the booking of appointments and for general information demands in this mountainous region with dispersed settlements and villages.

The new integrated health system covers the whole Region of Friuli Venezia Giulia and hence has an outreach of 100%. About 20% of the General Practitioners are already using the system; i.e. their patients data is included and accessible in the system.


1.2 Problem addressed

1.2.1 Specific Problem

Specific problems addressed: • Existing health

information system had to be adapted to the new possibilities offered by ICT

• The existing services could be improved in order to offer useful and efficient services

• Gathering of medical information of citizen to be stored in 'medical records' which was aimed by the health authorities was not possible

Since 1972 the Region of Friuli Venezia Giulia has understood that building a single regional system would lead to the development of the corresponding information system, whose main actors have always been the health authorities and the highly specialised hospitals.

The old health information system operating in the Region used to recover the medical and clinical data from the public health structure components, from the hospital and from other territorial activities, whereas the family doctors were strategic actors in the healing process, but yet too marginal from the point of view of the integration of the information systems.

Moreover, the general situation did not allow the gathering of a number of medical information about the single citizens, which in the regional definition system corresponded to the 'medical record' concept.

With the SISR-CR project, ICT is being introduced respectively their use has been optimised in order to electronically link the with health care concerned parties and provide useful features like e.g. a electronic Medical Record system. This allows for a more efficient use of medical data, rationalised workflows, and the improvement of service provision for professional users and patients.

The general Italian and the regional health systems deliver health service to all the resident population and are financed by general taxation.

The Regional Health Administration (RHA) of Friuli Venezia Giulia is subdivided in six Local Health Authorities (LHA) that are managed as public corporations (figure 1). LHA's are mainly responsible for the provision of primary care.

Six hospitals have been constituted as independent public corporations (HIPC) while the remaining hospitals for acute cases (H) were directly managed by the LHAs. There were also five private hospitals. Overall, 92% of hospital beds were located in public hospitals whereas 8% were provided by the private sector.

Service: • Improvement of the

health care domain and its services to professional users and patients.

Types and level of agencies involved: • Regional Health

Administration (RHA) • Local Health

Administration (LHA) • Six hospitals

constituted as independent public corporations

• Various hospitals for acute cases

• Five private hospitals • (Ca. 1,200 general

practitioners)

Approximately 1,200 General Practitioners (or family doctors) operate in the region, covering the entire resident population. Their activity is regulated by a general contract with the Local Health Authorities. The objective of the General Practitioners (GP's) is to take care of their patients' general health status. They authorise the access to inpatient and outpatient facilities and they are responsible for most of drug prescriptions. Thus, GP's play a key role in the regional health system as well as they do in other European countries.


SISR-CR information system is a crucial step towards creating a provincial regional Electronic Health Record (EHR) for every resident in the Friuli Venezia Giulia Region. This means that care providers will eventually have access to relevant aspects of their patients' medical history from anywhere across the region and across all health providers. Patients will no longer have to repeat the same medical history over and over again.

In terms of interoperability, the specific requirement was it to achieve IOP between different stages of a supply chain, i.e. between the independent public hospitals, the Local Health Administration, and the Regional Health Administration; whereby the hospitals of acute cases are directly managed by the LHA's.

IOP requirement 1: IOP between different stages of a supply chain producing one or more services, i.e. between hospitals and Health Authorities

RHA: Regional Health Authority LHA: Local Health Authority HIPC: Independent Public Corporation Hospital H: Hospitals for acute cases

Figure 1: Interoperability Requirement

Besides, in the SISR-CR project, IOP between different stages of supply chain producing one or more services has also been achieved. In particular the picture (figure 2) shows the supply chain for services of prescription – booking of exams – medical report.

IOP requirement 2: IOP between different stages of a supply chain producing one or more services, i.e. between the channels offered in order to access or apply for information


Figure 2: Interoperability Requirement 2

The first chain node is GP, but the project is spreading the diffusion of electronic prescription to more authorised health operators belonging to different LHAs. This means to raise the level of service provision for citizens.

For laboratory results the SISR-CR project team is analysing the adoption of an international standard named LOINC (Logical Observation Identifiers Names and Codes) to facilitate the exchange and pooling of results, such as blood haemoglobin, serum potassium, or vital signs, for clinical care, outcomes management, and research.

This will raise the IOP level and will allow developing real-time monitoring and multi-channel alarm systems.

Another IOP requirement in the SISR-CR project has been to guarantee IOP between different services referring to the same customer and resorting to its Electronic Health Record (EHR).

IOP requirement 3: IOP between different services referring to the same customer and resorting to EHR

EH

R

Figure 3: Interoperability Requirement 3


Patient-centric schema, IOP between different services produced as result of IOP between different steps of the supply chain, are the main points on which SISR-CR project is based to achieve the continuity in the medical treatment.

In order to meet the three IOP requirements, the model of standardised workflows among the different actors (IOP requirement 1), among the various channels in order to receive medical information (IOP requirement 2), and for the access of the Electronic Health Record (IOP requirement 3) has been employed. These standardised workflows allow for mulitlateral communications among the various actors.

Basic organisational model employed: Multilateral communication between Health Agencies on all levels and to customers

Service delivery model: IOP among back offices (Booking system and laboratories) and between front-office and back-office (bilateral) for all other activities involving GP, citizens and Health Agencies

Re-organising the regional health system by providing standards which have to be commonly used and hence an 'infrastructure' that links the various actors and enables exchange and integration of data (booking system, laboratories), activities mainly focus on back-office to back-office processes. And with regard to the general service provision involving GP's citizens and Health Agencies, IOP has been achieved in the front-office to back-office processes.


1.2.2 General Background

Friuli Venezia Giulia is one of the Italian regions where the social-health services are still steadily rooted in the public system. In this context the local Public Administration has developed a privileged relation with the consumers.

Background aspects: • Social health services

are steadily rooted in the public system and have developed a privileged relation with consumers

• Administrative and legal devices of putting the citizen in the centre of deliberative democracy

• Improvement of eGovernment in Italy in general

• Health services are of the top priorities wished by citizens to be applied for electronically due to recent surveys on European as well as on Italian level and due to Nielson Net Ratings

The integrated regional health services during their development have always paid attention in putting the citizen at the centre of the deliberative democracy that is going to be created because of administrative and legal devices, which widen the real democracy with the participation of the citizen/resource to the project regarding his/her health and the health of all, his/her well-being and the well-being of all the population.

This system encourages, protects and emphasises the meaning of the personal autonomies. In this way the citizens are invited to set the rules of a new co-existence, and they play a key role by integrating them in the system. Moreover, they acquire the unprecedented opportunity to make their interests and more complex needs understood which was not possible up to the recent past. Indeed, a recent survey at a European level has shown that health services (especially the booking service) are a priority among all the possible services that the citizens would like to use within the net. Through the creation of a new model the Public Administration wishes to bridge the gap between itself, the system that offers the services, and the citizens as consumers.

Moreover, eGovernment is no more a taboo for the Italians; on the contrary, it has become a useful instrument to access, with the help of the Personal Computer, the services offered in the network by the Public Administration from home and without time limits. 62% of those, who have visited the websites of the Public Administration are 'definitely satisfied' (very, fairly satisfied) with the online services. The data come from the survey carried out by Nielsen Net Ratings, in May 2004, a research suggested by the Observatory of the Information Society, on behalf of the Italian Minister for Innovation and Technology.

The survey has involved the users in an interactive way by inviting them to 'draw' the Public Administration they would like to have and the services they would like to find online. The most needed services were the health ones (41%).


1.2.3 Policy context and strategy

With the reform of Title V of the Italian Constitution, the roles in the governance of the territory of the public administration, of the citizens and of the companies have been re-defined. The clearest effects of this will be produced on the regional government levels, which will witness a progressive process of the 'constitution' of the active citizens, so that the administrations will have the duty to support the initiative of the single or associated citizens.

Legal framework • Re-definition of the

roles of citizens and businesses in the Italian Constitution which, among others, effects the local and regional authorities so that they have the duty to support the initiative of the single or associated citizens

• Guidelines of the Government for the development of the Information Society in the legislature with the main objectives to put the citizen at the centre, create greater availability of the service, simplify procedures, and optimise production activities

Generally, the model the Government wants to implement is a public administration, oriented towards the user (citizen and company) and which can offer modern services, create 'public value' and easy usable systems.

An efficient and transparent public administration in its duties and in its wide information heritage is first of all an innovation and competitiveness factor for the country. The establishment of such a model of eGovernment is based on modern 'qualifying infrastructures', which ensure with efficiency and security several basic functions.

An eGovernment system, with its more advanced development, will become a powerful tool for the involvement and the participation of the citizens to the decision-taking processes, thus evolving towards innovative models of eDemocracy.

Such a path can be established only if it acts in a coordinate way on all the components: normative, financial, organisational, procedural and above all on human resources, which are necessary for all the huge transformations.

Within such a model eGovernment is a fundamental innovative passage, which is involved in the deep transformation process that is implementing all the public bodies to serve the citizens and the companies as if they were 'clients' to be treated with the highest possible attention. The concept of the client does not mean that the administrations operate in a profit point of view, but that its objective becomes offering the services on the basis of the needs of the users.

Strategic Reference Model: The Italian eGovernment strategy foresees several core elements determined in a Strategic Reference Model: • Distribution of the

services • Digital recognition • Access channels • Distributing bodies • IOP and cooperation • Infrastructure and

communication

The satisfaction of those who use the service is a fundamental means of assessment of its quality. It shall be underlined that among the 'client' citizens the same rights and opportunities are to be granted to Italian citizens living abroad, and for this specific objective the technology has a key role.

To implement in practice this new user/service concept, the following model for strategic reference of eGovernment has been developed, and it is made-up by six core elements:

− Distribution of the services;

− Digital recognition;

− Access channels;


− Distributing bodies;

− Interoperability and cooperation;

− Infrastructure and communication.

The "guidelines of the Government for the development of the Information Society in the legislature" approved on the 31st of May 2002 by the Council of the Ministers and then presented to the unified Conference State-Regions-Cities and Local Autonomies, have traced the basis of the path to be followed by the public information system, thus encouraging these new dialogue channels and the interactive services for the citizens.

The guidelines, traced by the Minister for Innovation and Technology, determine the transformation of the public administration as regards the information technologies and communication, in the wider context of the development of the information society. They point out:

− the initiatives linked to the ten main objectives of the legislature and specific objectives for each administration;

− the need to rationalise and optimise the current expenditure for the information systems for all the administrations.

The relation between the citizens and the regional administration through the Internet will be interactive and it will allow carrying out a dialogue and handing out the necessary documents due to the employment of information instruments.

The basic decisions which have oriented the development of a complex system are aimed at meeting the fundamental objective of the Regional Health System to:

− put the citizen at the centre of the system,

− create a greater availability of the service,

− simplify the procedures, and

− optimise the production activities. Strategy of Regional Health Service: • Conduction of a

precise analysis and re-definition of the organisation of the single components of the processes in order to develop a high technology eGovernment system which respects the privacy of the citizens

In this view they have set up a system, which can involve in the process the general medicine doctor, as s/he has all the information about the health situation of each patient and s/he may help the citizens to access the health services.

To carry out this strategy through a precise analysis and the re-definition of the organisation of the single components of the process, they have firstly developed a high technology eGovernment system, which respects the privacy of the citizens.

The region will guarantee the necessary investments to meet this objective.


1.3 Solution

1.3.1 Specific Objectives

Objectives to be achieved in general: • Creation of an

integrated health care system

• Inside this, creation of a web portal, call centre and a Citizen card

The project "Continuità della Cura" (Continuity of the medical treatment) is aimed at the creation of an integrated system for the Regional Health Agency and for the Regional Health Services authorities. The system allows the management and distribution of health services to the citizen and to the specialised consumers and the integration with the clinics' software of the general medicine doctors and of the paediatricians working as free professionals.

The fundamental guidelines supporting the whole system are those developed by the eGovernment project of the SISRCR (Regional integrated health services for the continuity in the medical treatment) and namely: the Call Centre, the Portal and the Citizen card.

The main objectives of the project are the following:

− Simplify the access to the services: decentralisation of the access and information points, in order to avoid useless accesses for the gathering of medical reports and information;

− Optimise the resources of the Health services authorities: the objective is not reducing the expenditure by reducing the resources, but reducing the cost of the services because of the rationalisation of their use; completing the 'information circuit', prescription, medical authorisation – reservation, acceptance/reception desk distribution, drawing up medical reports, handing out the results;

− Create a database of the patient: in line with the privacy laws (which are fundamental for the quality of the medical treatment);

− Interoperability between the authorities: for an operational and informative exchange with the highest possible level of efficiency;

Specific objectives to be achieved: • Simplification of

access to services by de-centralisation of access and info points

• Reduction of the costs by increase of efficiency of the resource use

• Completion of the 'information circuit' in the services

• Creation of a database with patient data in line with privacy laws

• IOP among authorities • IOP between the

health system authorities and the region − Interoperability between the health system authorities and the

region: for the best management of the patients and for an exchange of information between the two bureaucratic levels.


1.3.2 Implementation

To achieve the scope of employing an integrated regional health system, several layers of IOP are concerned, syntactic, semantic as well as organisational interoperability.

Case capitalises mainly on following layers of IOP: • Syntactic IOP: SOA

builds the basis for the regional communication structure based on standardised workflows and exchange standards

• Semantic IOP: agreed data standards for accessing the information system and enabling the use of different access channels are employed as well as unique interpretation of data for each event type have been defined

• Organisational IOP: SOA as basis for new communication network. Workflows have been changed as well as new ones introduced. A central Medical Record database has been established and new access channels employed

Syntactic interoperability is embedded in a SOA model (Service Oriented Architecture) using the regional network that links LHA, RHA and hospitals as transport infrastructure. Syntactic rules warrantee the information exchange among these actors and have been employed together with the semantic rules.

Semantic interoperability guarantees the different actors involved in different stages of the supply chain the possibility to qualify in univocal way the content of the medical documentation, apart from role and tools used to access services. It is important to highlight that GPs can use different tools to interact with SISR-CR information system, choosing between web tool of SISR-CR project or other own tools integrated with the central system interface in accordance with regional interoperability specifications (public document).

Semantic interoperability is based on: − national laws on drug prescription and medical order writing;

− national and regional code for drugs, visits and exams;

− ICD9-CM for diagnosis.

− diffusion of HL7 messages for communication and HL7 CDA2 for clinical documents

Specialised services are implemented to guarantee the working flow in accordance with above-mentioned points

But continuity of treatment also means semantic interoperability across every process and every actor, no matter if it belongs to the front office or back office layer. This is achieved with unique interpretation of data for each event type fired in different steps.

More, this allows RHA to monitoring activities and to catch the right meaning from clinical data analysis.

Since workflows among the actors had to be changed or adapted, new possibilities with the central database with the Electronic Health Records emerged, and further channels (basic components) for applying and accessing health related information (web portal, call centre, services system) have been employed, organisational interoperability is also in the foreground.

Supporting infrastructure employed: • Electronic Health

Report database • Portal of the Health

Service • Call Centre • Services System

(Smart Card)

Basic components

Beside the development of the Electronic Health Report repository (EHR) the developments in the SISR-CR project mainly cover the following basic components:

− Portal of the Health Service

− Call Centre

− Services System


PORTAL of the HEALTH SERVICE The Portal is developed on a multi-level structure in the Internet/Intranet systems and it is planned to meet the needs of a heterogeneous target (citizens, specialised customers, hospitals or health authorities) with different objectives.

The Intranet reserved area can be accessed by the general medicine doctors and by the Paediatricians working as free professionals for all the service of the outpatient departments and particularly to prescribe medicines and health services, online medical authorisations, certificates, and anamneses.

The Portal guarantees the access to integrated information regarding the main themes of the public health (services, interventions, waiting time, health procedures and proceedings, facilitations, associations, prevention, high specialised centres, etc.).

One single access point will guarantee the access to the patient-health data (clinical history, diagnostic results, etc.).

Moreover, a rational and structured access to the clinical and health services will be offered due to the online reservation/acceptance of the interventions (CUP).

Benefits of Portal: • Centralisation of the

patient in the whole sanitary system

• Interactive and personalised services between patients and health authorities

• Easier access to services

• Spread of information by introduction of call centre structures

• fruition of the integrated services for identification of the patient and for CUP reservations

• Possibility to chose the structure with the shortest waiting times due the comparison of services and interventions by publication of the waiting times

• Visualisation of information about pharmacies and there opening shifts in the Region

• Simple and intuitive surfing within all portals of the Health Service Authorities

• Organisation of a single access point to the health system

The benefits for the customers are the following: − Centralisation of the patient in the whole sanitary system;

− Activation of interaction processes between the citizen and the health structures through interactive and personalised services to manage the requests for further information, the advices and the proposals, to hand out notices and news, and to participate at the thematic forums with the specialised structures;

− An easier access to the services offered by all the health structures of the regional territory;

− Set up a unified call centre structure to spread information, for the reservation, modification and cancellation of the health services prescribed by the general medicine doctor;

− Fruition of the integrated services for the identification of the patient and for the CUP reservations;

− Direct comparison between the services and the interventions, so as to guarantee the opportunity to choose the structure with the shortest waiting time (thanks to the publication of the waiting times regarding all the Health Services Authorities in the region on the portals);

− Visualisation of the information about the pharmacies on the whole territory and about the corresponding opening shifts;

− Simple and intuitive surfing within all the Portals of the Health Services Authorities, thanks to the uniformity of the graphical and functional structure;

− Organisation of a single access point to find the information regarding the health system in the whole region ("portal" of the health portals).


CALL CENTRE The Call Centre is an alternative and complementary solution to the other components of the system in order to support the interaction processes between the Health Authorities and the citizens.

The offered services allow different accesses to the system and give information or new contacts on the basis of the customers' needs respecting the criteria of the 'Customer Relationship Management' among which the ability of the single authorities to manage the relations with the client for him/her to be always satisfied are to be highlighted.

The first level of the eGovernment architecture is about the front-end towards the citizen and it envisages a multi-channel interface (which may be accessed through different tools and channels), which represents the contact point between the customers and those who offer the services. Thus, beyond the traditional services, the system will be able to also offer the online services, thus developing new and sounder relations with the citizens.

The Call Centre allows more streamlined and faster processes, as when the citizen/client calls the service, the operator has already all the necessary data of the medical authorisation.

SERVICES SYSTEM The smart card is seen as a second security level. In particular, it is used to view and offer the pharmaceutical and medical authorisation prescriptions of the general medicine doctors and of the paediatricians working as free professionals for the corresponding distributions/prescriptions in the authorised pharmacies and in the centres for the reservation of the medical visits (CUP), thus guaranteeing the identification of the user and the privacy of the data.

Benefits of Call Centre: • Enabling of more

streamlined and faster processes

• Call centre operator already has all necessary information of the medical authorisation

Benefits of Services System: • All data useful to the

doctor are present in a central archive can directly be inserted into the medical authorisation

• Reduction of the flux of patients who could not reach the end of the processes for the service reservation

The system offers many advantages in the doctor/patient relation as all the data which are useful to the doctor are present in a central archive and can be directly inserted in the medical authorisation.

Warranty of security and privacy: • Registration feature at

the portal as first security level

• Access to the clients' medical reports requires the use of a Smart Card

• Other opportunity would be to access and consult the data via the family doctor

This may solve many problems often met by the citizen during the reservation of a service; for example the possible difficulty to understand the doctors' hand writing.

Indeed, the doctors who have tested this new system have noticed a reduction of the return flux of patients, who could not reach the end of the process for the service reservation. This flux in the past reached even a 20% level.

The safeguard of security and of privacy is guaranteed, as the citizen/client has two opportunities:

− access the corresponding data of his/her own medical reports by using the Card;

− appoint the family doctor to access and consult the data.

The project envisages the citizen as the only owner of his/her own data. In the case of an electronic access, the Card becomes the only



GP is absolutely free to decide to give that service (to book the exam) to his patients or to let patient to negotiate place and time for exams for example with call centre. Call centre operator (as well pharmacy or front office operators) can access electronic GP prescription, directly from booking system interface, and book it in very short time and without errors. Booking system is integrated with the Hospital Information System. In this way laboratory for example have direct access to their daily working list. When citizen will go for an exam, the medical report will be available directly to the GP and her/his patient.

In particular, medical orders will be available to the multi-channel booking system (GP, Pharmacy, Call Centre operator, front office).

In this way prescriptions will be available to all system actors.

GP can use GP Portal to record the visit, check patient health history, record clinical data and write electronic drug prescription or electronic medical order.

The needs could be to go for a visit to the GP (check-up , follow-up etc.).

Citizen needs can be general information about RHA, LHA, Hospitals, Pharmacies and GPs in the territory as well as queue time for exams, prices, contact number and addresses or other health information. In this case citizen can choose different ways to access information: LHA portals, RHA portal or just to speak with a call centre operator.

The starting point of the flow is the citizen with her/his needs (see workflow diagram on next page).

Workflow description

In both cases, the form to be filled-in can be downloaded from the Portal.

access key to the patient data, even in the case of other specialised doctors. Moreover, the patient chooses which data can be accessible to other users. The citizen shall follow important steps in order to safeguard the privacy:

− authorise the doctor to manage the data.

− consent to the electronic treatment of the data;

Warranty of security and privacy: • Patient is the only

owner of her/his data and can decide which data shall be accessible by others. In this sense (s)he has to give consent to the electronic treatment of data and authorise the doctor t manage the data

: Health services in F.Venezia G. – Italy 05-2006, vs. 1.0 16

GP Case

1.4 Features making it a candidate for good practice exchange

1.4.1 Impact

Outreach: • 100% for the whole

Region • About 20% of GP's are

already using the system

The innovation deriving from this project has lead to a change in the back-office activities, which, in the case of the Trieste Health Authority, has been the re-definition of the role of the staff working at the services windows, which have been trained as call-centre operators.

The new integrated health system covers the whole Region of Friuli Venezia Giulia and hence has an outreach of 100%. Beside the regional and local Health Authorities and the publicly owned hospitals, almost 20% of the General Practitioners are already using the system; i.e. their patients' data is included in the system and centrally accessible (by authorised persons). Countable results of the SISRCR project can be stated for some call centres and the CUP windows. Statistics of the Udine and Pordenone inter-authority Call Centre (period: 3rd January - 4th March 2005) are as follows:

The target involved in the project has the following elements: − Citizens/patients

− Regional Health Authority

− General medicine doctors

− Paediatricians working as free professionals

− Medical-scientific operators

− Health authorities

− Hospitals and Laboratories

Performance (call centre Udine and Pordenone): • ca. 10,000 calls per

week, i.e. 2,015 per day of which could be answered 1,913

• Among the answered calls, 843 were reservations

• Concentration of calls in the morning hours

Presently, the call centre is working from 8:00 to 17:00 from Monday to Friday. There are 21 working centres, which are all active during the peak hours (9:00-12:30). There are 24 operators working full-time.

The amount of the contacts, monitored in the first two months of the year 2005 is the following:

The call-centre has received more than 10,000 calls per week of a total amount of 88,682 calls, 84,165 of which have been answered (daily average of the received calls: 2,015, 1,913 have been answered. Among the answered calls, 843 were reservations).

As regards the distribution of the calls, a major concentration during the morning hours can be noticed.

Performance (call centre Trieste): • ca. 19,000 calls in

total in first quarter 2005

General statistics of the Trieste Health Authority (beginning of January - end of March 2005)

Call Centre: total answered calls 19,110 Performance (CUP windows): • Total answered calls

102,482 in the first quarter of 2005

CUP windows (centres for the reservation of the medical visits, namely pharmacies and windows of the Health Authority): total answered calls 102,482.


1.4.2 Relevance of the case for other administrations that could learn from the experience

Innovativeness: • Provision of integrated

health services for the whole region, based on integrated multi-channel access

• Provision of a central database with all medical reports of the region's patients

• Provision of user friendly and efficient service by the call centre since operators are already supervising all the data of the medical authorisation. On basis of the code written on the medical receipt, the operator immediately identifies the calling patient and the necessary service

• The same is for the cancellation of a reservation which is also done by a code

The most important lesson learnt during the implementation of this project is that the system needs to be flexible at an organisational level, in order to adapt it to the needs of the territory.

This flexibility offers the doctor the opportunity to decide whether to carry out the traditional procedures or rather supervise all the movements of the online medical authorisation, which varies on the basis of the territorial needs of the specific area where it is set.

The territory is full of different features and so it presents different needs and different fruition procedures for each service. As regards the Friuli Venezia Giulia region is quite normal to note very different approaches to the use of the health system by the doctors in the mountain areas and by the doctors working in the towns.

They have noted that in the marginal zones, such as the mountain area, the general medicine doctors prefer using the system by completing the process up to the online reservation of specialist medical visits and of medical exams. The benefits, deriving from this kind of approach to the system, are visible in the health status of the patients and in the improvement of their quality of life, as the systems find an alternative to the inconvenience of travelling from villages set on the mountains to the centres in the valleys to enjoy the health system services.

On the contrary, the doctors in the towns rarely use the online reservation system. This happens because the use of the new technologies require some minutes of time, which, if multiplied with the high number of the patients, causes an unsustainable expenditure of time. On the basis of the Italian current legislation, a doctor may have a maximum number of 1,500 patients, and this number is always met in medium-large cities. In the mountain areas, which have a much smaller population, this never happens and for this reason the patients can be offered an additional service without creating any problem as regards the waiting times in the outpatient departments.

In the towns the service is usually divided into the 'medical authorisation' and the 'reservation' and the citizen-patient prefers to conclude the sanitary process by using the call-centre.

The Call-centre system is a multi-channel and multi-user network, which supports the applications for the elaboration of the information, included the monitoring of the phone call and/or the development and progress of the call itself.

The call centre allows more streamlined and dynamic processes, which lead to a best customer satisfaction.

The very innovative issue for patients of this is that when the citizen/client calls the call centre, the operator is already supervising all the data of the medical authorisation. On the basis of the code written on the medical receipt, the operator identifies immediately


the calling citizen and the necessary service; the next step is simply deciding where and when to implement the needed service.

The same simple proceeding applies for the cancellation of the reservation: this may be done by phone thanks to a simple code.

The advantages of these new standards allow the patient to eliminate the inconvenience of queuing in long lines at the traditional windows and to eliminate the possible problems of the operators at the windows in understanding the medical authorisation. Moreover, the costs of the health system are considerably reduced.

This system encourages, protects and emphasises the meaning of the personal autonomies.

1.4.3 Transferability

The following three solutions have been defined for a possible use of other authorities.

1st Solution – On line health services The first level of the service is about the front-end towards the citizen and it includes a multi-channel interface representing the meeting point between the users and those who offer the services. The service is organised on the basis of an integrated information and booking system (CUP), through which the citizen can access the working times of the pharmacies and of other health system windows, s/he can book medical visits and be informed about possible waiting times of the different health structures.

Transferability: • Three solution could

easily be transferred to other authorities: On-line health services, On-line doctor, and On-line medical reports

The second level is based on an Intelligence Integrated System for the Health online booking and it represents an alternative and complementary solution to the other components of the integrated system to support the interaction processes between the health authorities and the citizens. The system includes both the specialised customers (health operators, doctors, pharmacies, etc.) and the users/citizens, thus developing the most possible streamlined and fast processes for the access to all the health services, together with a Best Customer Satisfaction.

INFORMATION AND BOOKING INTEGRATED SYSTEM A front-end level including an interface which is accessible through different instruments and processes is addressed to the citizen. It is a privileged contact point between the citizens and the Health Authority (which offers the services) in order to support the traditional services with new online services, thus developing modern and more sound relations with the citizens.

The services allow different accesses to the system and they mediate different information and contacts on the basis of the stated needs,


always respecting the "customer relationship management" criteria, among which the ability of the single authorities to manage the relations with the clients and guarantee his/her satisfaction is to be highlighted.

The system enables the functional integration with the booking system CUP (medical authorisation, bookings, etc.) and with the information and booking integrated system (waiting time, booking, etc.).

The multi-channel and multi-client system supports programs for the treatment of information, included the monitoring of the phone call and/or the development and progress of the call itself.

This integrated system promotes and supports the "medical treatment continuity" for the patient and it enhances the following criteria:

− The patient becomes the centre of the attention;

− Easier access to the services offered by all the bodies.

INTEGRATED INTELLIGENCE SYSTEM FOR THE HEALTH ON-LINE BOOKING This system represents an alternative and complementary solution to the other components of the system in order to support the interaction processes between the Health Authorities and the citizens.

The system will be supported by a call centre, thus giving the service more streamlined and fast dynamics, together with a best customer satisfaction.

For the benefits of this system concerning the recognition of a patient calling the call centre via a written code and others, see the previous chapter.

2nd Solution: on-line doctor This is a web-ambient solution, which includes certificates with digital signatures, an integrated interaction with the pharmacies, web services.

With the online doctor system the citizens, the operators of the health system and the government can benefit from the advantages of the project by improving the quality of their work, of the medical treatment and of the offered services.

The family doctors can guarantee the citizens a better service in the activities, which regard the pharmaceutical and outpatient departments - prescriptions.

Transferability: • Information and

booking integrated system and Integrated Intelligence System for the Health online booking as parts of the On-line health services

Moreover, they can obtain from the system vast and precise information about each patient (principal health elements and medical reports) and about the available services, all this respecting the privacy, guaranteed by the security services of the system. Lastly, they benefit from the cooperation with the Health Authorities and among the professionals of the sector.


The pharmacies may consult the medical prescriptions of the general medicine doctors and they provide assistance to the citizen in the booking of the services.

Moreover, the medical prescriptions may be consulted during the booking of the medical authorisation, which is reserved at the CUP centre directly by the doctors or by the authorised pharmacies, which have access to the portal. During the booking process the patient is informed about the available structures where the needed service is offered so that s/he can choose the most suitable solution.

The improvement of the services leads gradually to the reduction of the queuing at the windows and of the waiting time to benefit from the basic services.

The system is ideated to progressively widen its advantages to the health structures offering the services to the customers (e.g. Clinics, Laboratories for the analyses, Health authorities and Hospitals), which will then offer a better service to the citizens, as for example in the services booking system, in the cooperation with the general medicine doctors, in the integration of further data on the clinical history of the patients, etc.

Each portal has an Intranet eGovernment area, used by the specialised customers to prescribe medicines and health services. Beyond the registration of the portal, the system adopts the smart card as a second level of security. It is used to arrange and distribute the pharmaceutical prescriptions and the medical authorisations and for the corresponding distribution/prescription in the authorised pharmacies and CUP centres. The combined use of the doctors' paper documents and of the service system allows a greater visibility on the medical reports.

3rd Solution: On-line medical reports Before the introduction of the new information technologies, the recording system based on documents and reports printed on paper had numerous and clear disadvantages: most of all there was a high wasting of time and staff in the pre- and post- analytical phase and a fragmentation of the patient identification process.

With the online system, indeed, the doctor can directly type on his monitor the necessary exams for his patient (with the opportunity to modify them or add new elements in real time) and print the necessary identification codes. After the test tubes have been handed out to the reception point, the doctor will immediately be informed on his/her computer about the results of the needed exams, without waiting for the manual delivery of the results paper. The system is structured in order to send, in an electronic format, the text and the images of the exams (analyses, x-rays, etc.) the patients have done in the laboratories both to the internal operators and external customers (doctors and patients). This system is an important innovation both from an economical and technological point of view.


1.5 Results

IOP and Continuity in the Medical Treatment

Impact: • Set up of new

communication and dialog standards among the actors

• The patient is offered to access medical reports by its Card or to delegate it to the family doctor

• Coexistence of electronic processes with traditional processes also by multi channel access

The project has paid particular attention in defining two different frameworks of the medical treatment processes, in order to set new communication and dialogue standards between the Regional Health Service, the General Medicine Doctors and the Health Authorities.

With the new system the citizen is offered two opportunities:

− Access the data of his/her own medical reports thanks to the Card

− Delegate the family doctor to access and consult the data

Moreover, the system envisages the coexistence of the electronic process with the traditional process. In this way the procedure is much more streamlined and convenient than in the past. Indeed, once the doctor has issued the prescription on paper, the citizen has many opportunities to complete the process:

− Go to the window, where the operator has already got the electronic prescription

− Go to the CUP window of the pharmacies, thus reducing the distances

− Manage the medical authorisation by calling the Call Centre

Continuity of the treatment means also giving an easier access to the services, dedicating more attention on the orientation and information of the citizen about the whole offer of the health service, so that s/he can freely choose among the available offers.

Surfing in all the portals of the Health Authorities is very simple and intuitive. Thanks to the graphical and functional structure, a single access point is guaranteed in order to find the necessary information regarding the whole region ('portal' of the health system portals).

Indeed, all the data, which are necessary for the doctor, are saved in a central archive and can be filled-in with the medical authorisation, thus eliminating the errors in the medical prescriptions.

Also, saving a document on a CD-Rom and sending it in the net means a two thirds saving on the expenditure.

For the specific benefits of the three basic components (Portal, Call Centre, Services System) see the Implementation Chapter above as well as for the on-line health services, on-line doctor, and the on-line medical reports the previous chapter.

To summarise, the effects for public authorities and patients are as follows:

Advantages for the Health Authorities:

− Optimisation of the laboratories management with the opportunity to rationalise the remote centres;

Performance: • Easier access to

services • Simple and intuitive

surfing on the health portals

• All necessary data are saved in a central archive and can be filled-in with the medical authorisation

• Savings of up to 2/3 of expenditures by online treatment

Benefits for Health Authorities: • Optimisation of the

laboratories management with the opportunity to rationalise the remote centres

• Constant monitoring of the process

• Optimisation of the archives management

• Avoid the problem of the miscarriage of the documents


− Constant monitoring of the process; Benefits for Health Authorities: • Reduction of the staff

involved in the management of the documents

• Reduction of the displacement of auxiliary staff

− Optimisation of the archives management;

− Avoid the problem of the miscarriage of the documents;

− Reduction of the staff involved in the management of the documents;

− Reduction of the displacement of auxiliary staff.

Advantages for the citizens

− The citizen will have the opportunity to choose how to access the medical report with the digital signature (internet, post, general medicine doctor or window);

Benefits for Citizens: • The citizen will have

the opportunity to choose how to access the medical report with the digital signature

• Reduction of travel and hence transport costs

• Best use of time • Higher security and

privacy than paper-based procedures

• Immediate access to data

• Streamlined procedures

− Reduction of the travels, which leads to a reduction of the transport costs;

− Best use of time;

− A higher security and privacy in the treatment of the data than with the paper-documents system;

− Immediate access to the data with the guarantee that the security systems allow streamlined procedures.


1.6 Learning points and conclusions

Critical success factors for IOP:

Take care of the flexibility of the system at the organisational level

• Take care of the flexibility of the system at the organisational level in order to be able to adapt it to the different needs of the territory

The most important lesson learnt during the implementation of this project was that the system has to be flexible at an organisational level in order to adapt itself to the needs of the territory. The territory may have different features and therefore different needs for service, together with different fruition types.

Enrich the service provision by e.g. Multi-Channel access and use modern technologies

• Enrich the service provision by e.g. Multi-Channel access and use of modern technologies as factors for success

Another success has been reached thanks to the access granted to the multi-channel services and thanks to new technologies such as the Portals, developed Call Centres, the Smart Card, the Citizen Card; all this has allowed the evolution of a new regional health system.

Thanks to these new channels the sanitary offer has been enriched and new contact points between the health operators and the customers have been created. The monothematic health offer has been transformed in an articulated system with different intensity and needs levels (hospitals, RSA - Health help residences -, bodies for non-autonomous patients, home treatments, etc.) thus granting the access to the services, dedicating more attention on the orientation and information of the citizen about the whole offer of the health service, so that s/he can freely choose among the available offers.

• Create more contact points to your customers

• See reforming, re-inventing and modernising as the new challenges for better public services in order to meet the changing requirements of your customers

See reforming, re-inventing and modernising as the new challenges for better public services This is the new challenge for the future: reforming, re-inventing and modernising the social state. New needs need new solutions: ageing of the population, with a consequent raise in the chronic-degenerative pathologies (diabetes, hypertension, etc.), focus on the younger patients, on the families and on the modern problems.

• Start at the bottom to create tangible experiences, i.e. start with co-operations between the authorities offering the service in order to improve service provision for users

Start at the bottom to create tangible experiences To create tangible experiences one should start from the local planning, from the territory, with the implementation of the cooperation between the public and private institutions and with the creation of new contacts between the citizens and the bodies, which offers the services.



Enforce co-operation and enhance the dialogue within the public administration

• Enforce co-operation on applications and enhance the dialogue between the different elements of public administration in order to offer improved services

In this sense an application co-operation enforcement is needed in order to offer improved services and to enhance the dialogue between the different elements of the Public Administration, thus opening new communication channels towards the citizens.

Focus on the main actors first and convince them to collaborate Identify the main actors of the system in particular important for the use and outreach, hence the success of the project. In this project, the General Practitioners are crucial users of the system who "have" the patients (-data) and thus "maintain" their medical records, issue prescriptions and book appointments (etc.). I.e. the participation of the GP's is very important to facilitate the system use and to enrich the database of the medical records. Put these important actors in the centre at the beginning to achieve high volume from the beginning.

• Focus on the main actors, convince them to collaborate and hence achieve high volume of system use from the beginning

Guide the customers to your service offers The challenge of this new model is creating services such as:

− information services for the citizens who ask for help or who would like to know which kind of services are guaranteed by the District.

• Guide the customers to your service offers since not all tasks are known by them and easy to understand

− operative services, help the citizen not only to understand the procedures of the health system services and of the normative dispositions of medical help and prevention, but also to explain him/her how to access the services offered by the district in the social sector themselves, together with all the opportunities offered both by the existing legislative acts and by the services bodies on the territory. Not all tasks are always easy to understand. • Diversify the resources

for the funds and coordination Diversify the resources for the funds and coordination

The fundamental innovation is determined by the logic of the project itself. The resources for the funds and the coordination are diversified, thus guaranteeing the success of these projects, which determine the continuity of the medical treatments.



Respect defined standards The initiative and the corresponding action plans support the definition and the harmonisation of the politics for the innovation of technology; they also guarantee (thanks to the strict respect of defined standards) those communication mechanisms, which link all the components of the health world and, most of all, that connect on one side the regional systems, and on the other side the systems of the health bodies, the doctors' studies, the pharmacies.

• Respect defined standards in order to support the definition and the harmonisation of the politics for the innovation of technology and guarantee of linking all relevant components/ the actors Agree on standards for communication, shared working rules

and coding systems • Agree on standards for communication, shared working rules and coding systems since these are absolutely base requirements to build complex systems where especially interpretation of data is much important

Due to one or several different IOP requirements it is to be learned that availability of standard protocol for communication, shared working rules and standard coding systems are absolutely base requirements to build a complex system where interpretation of data is so important. More, a patient-centric approach is the model to guarantee the continuity of the medical treatment and the way to achieve IOP. All the system is designed around this model.

• Put the patient at the centre and build your system around her/him and use this model as way to achieve interoperability

1.7 References and links

Website of the Region of Friuli Venezia Giulia: www.regione.fvg.it

Service provider for the Region of Friuli Venezia Giulia: www.insiel.it

The six web portals of the Health Authorities in the region (partly in several languages): www.ass1.sanita.fvg.it

www.ass2.sanita.fvg.it






http://www.regione.fvg.it/

http://www.insiel.it/

http://www.ass1.sanita.fvg.it/






Annex 1: Assessment Questionnaire for the MODINIS Case Descriptions

In order to ensure the case descriptions meet the information needs of stakeholders in interoperability at the local and regional level, we ask you to complete this short assessment questionnaire. Your feedback will be used to improve the next version of the present case and will also be taken into consideration when writing up more cases to be described in the course of the project. Case being reviewed:……………………………………………………………………………………………………………………….… 1.) Information content a) Completeness of description 1 5 |-----------|-----------|-----------|-----------| only few all relevant relevant aspects aspects b) Detail of description 1 3 5 3 1 |-----------|-----------|-----------|-----------| too right too many general level details 2.) Length of description 1 3 5 3 1 |-----------|-----------|-----------|-----------| too right too short length long 3.) Structure / headings 1 5 |-----------|-----------|-----------|-----------| unclear clear


4.) Margins 1 3 5 |----------------------|-------------------- --| misleading not necessary good orientation 5.) Learning potential 1 5 |-----------|-----------|-----------|-----------| none at all many new insights 6.) Usefulness for your own work 1 5 |-----------|-----------|-----------|-----------| not at all very much 7.) Transferability of case to your country 1 5 |-----------|-----------|-----------|-----------| not at all very high 8.) Will you get into contact with the contact person? 1 5 |-----------|-----------|-----------|-----------| certainly for sure not Comments ______________________________________________________________________________ ______________________________________________________________________________ Your affiliation local/regional national IT academia government government business


Prepared by:

Ralf Cimander and Herbert Kubicek Institut für Informationsmanagement Bremen GmbH (ifib)

Am Fallturm 1, D-28359 Bremen, Germany www.ifib.de

Tel.: (+49 421) 218 26 74, Fax: (+49 421) 218 48 94, email: [email protected]

http://www.ifib.de/egov-interoperability

European Institute of Public Administration (EIPA)

Center for Research and Technology Hellas / Institute of Informatics and Telematics (CERTH/ITI)

Prepared for:

European Commission Information Society and Media Directorate-General eGovernment Unit Tel (32-2) 299 02 45 Fax (32-2) 299 41 14 E-mail [email protected] Website europa.eu.int/egovernment_research

http://www.ifib.de/

mailto:[email protected]

http://www.ifib.de/egov-interoperability

Date post:	19-Jul-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

IOP in Healh Care Services in Friuli Venezia Guilia · 1.3.1 Specific Objectives 11 1.3.2...

Documents