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1 Ministry of Economic Development Department of Communications DEPARTMENT OF COMMUNICATIONS A study of e-health in Italy by the principal component analysis Document available at: n R Elisabetta Santarelli elisabetta.santarelli@mise.gov.it Claudio Di Carlo claudio.dicarlo@mise.gov.it November 2012

2 Index 1. Introduction e-health in Italy e-health statistics in Italy Data, methods and research hypotheses Results Conclusions Acknowledgements Methodological appendix References E-health is defined as the use of emerging information and communication interactive technology, especially the Internet, to improve or enable health and healthcare. In a health system, e-health causes product and process innovations to which various disciplines can contribute (among which statistics). In this paper we make a review of the main statistical sources currently available in Italy on e- health, examining their potential and drawbacks, and analyze data from a recent survey on e-health to evaluate associations among its various dimensions by a statistical explorative technique. Results show that in Italy e-health development is higher in the North and Centre and that a low correspondence exists between supply and use of electronic health services. Moreover, e-health is developing by stand-alone initiatives without harmonization at regional and local level. These results suggest that a major integration among e-health initiatives is needed in Italy and pave the way for future research on such topic. The content of this work reflects only the opinions of the authors, and not necessarily that of the Ministry. 2

3 1. Introduction The application of ICT in health care is known by the term e-health, which incorporates everything concerning information technology, telecommunications, health and health care. The term was created in early 2000 in line with other e-words, such as e-commerce, e-business, e- solutions, with the aim of conveying the principles, promises, and developments of e-commerce to the sphere of health and health systems. The invention of a new term is entirely appropriate, given that the Internet has created and continually creates new opportunities and challenges for the traditional health care industry (Eysenbach 2001). Eng (2001) describes e-health 1 as the use of emerging information and communication interactive technology, especially the Internet, to improve or enable health and healthcare. According to the European Commission definition (2004: 4), e-health includes all ICT applications in the wide range of functions typical of a health system which concern doctors, hospital managers, nurses, data managers, social security directors and, of course, the patients through better disease prevention or management. The concept of e-health is very broad, therefore, ranging from IT and new technologies to medicine and health care management. It is a multidimensional concept. The first two dimensions concern the demand for and supply of e-health (as concerns citizens and the health care system, respectively) for commonly requested services: medical examinations, bookings, emergency medical services, first aid. The third dimension regards the technical infrastructure and the computer equipment necessary for the provision of services. The last aspect is cultural, since there can only be demand for and supply of digital services if the health personnel providing the services are computer literate (Di Carlo and Santarelli and 2011b). e-health tools and services cover a wide variety of products, systems and solutions, including electronic bookings, payments and withdrawal of results, electronic health records (EHR), and telemedicine, just to mention some of the most common applications. They include instruments for the organizational management and administration of the health system and for the prevention, protection and care of the health of citizens. When combined with appropriate organizational changes and the acquisition of new skills, e-health can help to develop prevention and treatments that are more effective, less expensive, easily accessible and quick. The use of ICT can reduce medical errors, mitigate or eliminate unnecessary treatments, shorten queues, and reduce and/or eliminate paper, thus producing savings and increasing productivity with benefits for both citizens and the systems that provide services. e-health is also of great benefit to the economy and 1 In this paper the terms e-health, health network, digital health are synonymous and used interchangeably. 3

4 productivity of a country because it provides incentives for employment and the creation of jobs (Stroetmann et al. 2006, Di Carlo and Santarelli 2011). e-health is a paradigm for innovation, involving a number of different disciplines: computer science, medicine, business administration and, not least, statistics. Indeed, the implementation and development of e-health cannot be planned without adequate knowledge of the characteristics of the phenomenon, for which qualitative and quantitative analysis are needed. To this end, relevant and reliable data are necessary to give a more complete picture of e-health. Currently, statistical data on e-health in Italy is scarce and where it exists it has to be checked for quality and reliability. The aim of this paper is twofold: a) to carry out a review of the main statistical sources currently available in Italy on e-health and analyse both the problems and the potential; b) to analyse data from a recent survey on e-health in Italy to evaluate the state of implementation of electronic services in our country. The results will allow to make a quantitative assessment of the spread of e- health in Italian regions and will form a basis for future studies on the subject. This paper is organized as follows: the next section illustrates the characteristics of the main digital health services existing in Italy; section 3 provides an overview of data sources currently available on e-health. Section 4 describes the data and methods used for the analysis, the results of which are described in section 5. Section 6 contains some concluding remarks. 2. e-health in Italy In Italy, health care is a regional responsibility 2. In 2010 there were 157 Community Trusts (ASL) 3 and 97 public hospitals (AO) 4 in Italy (Ministry of Health 2011). Health services employ about 650,000 employees, including medical staff and nurses, of which 48,000 are general practitioners (GPs) and 7,200 paediatricians. In all there are approximately 18,000 public and private pharmacies (Between 2010). The e-health situation in Italy is in line with European recommendations, which stresses the central role of ICT as a way of improving not only clinical diagnosis but also simplifying access to universal services (Ronchi 2010, Ronchi and Spiezia 2011). The Ministry of Health's role is to provide national directives and guidelines on e-health to regions and local health authorities to develop innovative ways of organizing and providing services, streamlining investment and ensuring synergy among stakeholders within a single strategic and institutional e-health framework (Ugenti et al., 2011) regions and 2 autonomous provinces. 3 Aziende Sanitarie Locali in Italian. 4 Aziende Ospedaliere in Italian. 4

5 Until recently the development of e-health in our country was linked to the initiatives of individual decision-makers who tried to respond to local priorities with the introduction of new technologies in health processes. In the absence of a common vision and communication among stakeholders, the initiatives were mostly spontaneous and depended on the context and the degree of awareness of individual problems. These initiatives were based primarily on a tolemaic approach, namely one that takes advantage of the new opportunities offered by ICT innovations but not as part of any systematic framework. Although the introduction of new technological solutions has led to immediate gains in efficiency, these have been limited and sporadic because of a lack of generalized organizational change (innovations in both product and process) and only partial use has been made of new technologies (Rossi Mori et al. 2012). Since 2000 we have been moving from an occasional use of ICT in health to e-health thanks to a new type of comprehensive copernican approach in which both policy makers and stakeholders place local, regional and national health plans at the centre of their actions. With the adoption of explicit and common health plans, health care processes have been modernized and health centres become coherent systems centred on citizens. In the future it will be possible to switch from e- health to connected health, adopting a holistic perspective, in which health care should not be based exclusively on technological solutions, but rather on the widest possible consideration of individual health (Rossi Mori et al. 2012). Italy has marked out a roadmap to e-health with the 2012 e-government plan, which aims by 2012 to simplify and digitize primary health services 5 and create the infrastructure necessary for the provision of services closer to the citizen, improving the cost-quality ratio and eliminating waste and inefficiency. Several projects have been initiated at the national level and implemented in consultation with the regions. Among these we list the projects to get all GPs and paediatricians online, to digitalize prescriptions (prescriptions and doctor s certificate), the implementation of the EHR 6, the creation of a single booking system to allow citizens to book national health services throughout the country. Many Italian regions are at the forefront in implementing e-health projects. For example, Lombardy, Tuscany, Emilia Romagna, Friuli-Venezia Giulia and Sardinia have started planning activities for the implementation of the EHR using chip cards and/or smart cards. In some regions there are single booking systems for a small number of health centres in the area. 5 Digital prescriptions and medical certificates, online booking systems. 6 The EHR is a collection of concise information on an individual derived from medical electronic records from health centres, hospitals, GPs and paediatricians. It contains all the information in medical records concerning the clinical status of the patient: diagnosis, admissions and discharges, specialist visits, results of examinations and X-ray type images, which are available online to authorized operators and the citizen concerned. The EHR is constituted by the regions, with the prior consent of the patient for the purposes of supporting and optimizing prevention, treatment, rehabilitation, emergency management and administration management (Ministry of Health 2010). 5

6 On the whole, the development of technological innovations in the national health system is still rather heterogeneous due mostly to poor coordination of the initiatives introduced. This consideration is reinforced by a survey conducted by Netics 7 in 2010 which shows that Italian regions have varying degrees of digital skills (calculated by the e-readiness indicator which contains 11 specific indices) ranging from 0.28 in Calabria to 0.82 in Emilia Romagna (Colli Franzone 2011). Because of the heterogeneous development of e-health, Italy does not have neither common definitions or standard assessment models, nor indicators that allow for quantitative evaluation. Similar problems exist in most advanced countries in which e-health systems have been implemented (or are being implemented). This will be the topic of the next section. 3. e-health statistics in Italy Considering that in Italy we are at an early stage in the implementation and use of e-health, the data and the indicators on the use and provision of these services are still scarce and, where available, are often inaccurate, not comparable, and out of date. Available data do not always give a full description of the spread of ICT applications in health care. This is mainly due to three reasons: the first is the decentralized nature of the health system, which makes it difficult for national surveys to show effectively the different ways in which central government directives are implemented at the regional level; the second relates to the complexity of the data gathering mechanisms, which are slow to adapt to heterogeneous and changeable situations such as the health sector (Istat 2009); thirdly, innovations in e-health are often unknown both to citizens and to healthcare professionals. However, the availability of statistical information and indicators on the extent and the speed of adoption of IT tools are of primary interest in a context such as Italy s where the use of ICT in healthcare is under development. At international level many countries share this information gap with Italy and for some time statistical offices and international organizations (Eurostat, OECD, WHO) have been urging member countries to set up indicators to measure the spread and use of ICT in healthcare (European Commission 2004 and 2008). A reliable evaluation of e-health would help guide the choices and decisions of policy makers. In addition, the policies of different countries could be compared if upto-date and comparable data and indicators were available, allowing to assess effectiveness, the 7 NETICS is a market research and strategic consulting company offering benchmarking and market intelligence services. The company sets itself apart for its expertise and experience of the ICT market and projects for the public sector. 6

7 links between incentives and results, the interaction between policies and existing institutional contexts, cost reduction and improved efficiency in time and space. Moreover, this would of benefit to the adoption and transmission of best practices that can be adapted in different cultural, social and health systems (Ronchi 2012). The need for up-to-date statistical information on e-health can be seen in Figure 1, which shows the spread of ICT innovations over time, the corresponding level of ICT activities and how these information needs may evolve. Indicators relating to infrastructure availability and access (the readiness indicators) are of great interest, especially where the use of ICT in health care is at an early stage. As e-health spreads countries would then begin to focus on intensity and impact indicators ( Ronchi 2010). Figure 1: Main information needs. Source: Ronchi (2010). To date, in the major OECD countries the most common e-health indicators regard the use of ICT for health services and for administrative and bureaucratic purposes. Nevertheless, a broader range of measures are needed to meet all the information requirements in Figure 1. The information provided by the indicators is essential to establish priorities, direct development, and implement health policies for the benefit of society as a whole. For example, indicators on EHR adoption measure the level of health care quality and quantity, allowing to monitor adherence to clinical guidelines and quality criteria, measure the results of system performance and monitor the spread of diseases. On the other hand, indicators regarding the level of user satisfaction can influence policies on the need for financial incentives to spread the culture of e-health among citizens (Ronchi 2010). 7

8 In most OECD countries data on e-health are not available from the usual health information systems and so an ad hoc survey is necessary. To this end, for some time the OECD has been promoting the implementation of a model survey to assess the spread and impact of e-health on the entire cultural and socio-economic system of individual Member States. Surveys should be flexible and adaptable to rapidly changing phenomena, such as information and communication technologies in healthcare (Ronchi 2010); standard modules, comparable both in time and in space, should be able to guarantee comparative data and derived statistics (Ronchi and Spiezia 2011). In Italy e-health data are currently produced and managed by administrative, management and clinical information subsystems which fall under the responsibility of several local authorities. The collection, storage and processing of such data is the result of decisions by individual health authorities and the same is true for conducting surveys. Since most initiatives involve local projects, the aims of the surveys, as well as the criteria for data collection (sampling, interview type, definition and classification of variables, processing of missing data), are often different, thus making it impossible to compare results. The administrative source par excellence for the collection and management of e-health data at a centralized level is the Ministry of Health through the New Health Information System (NSIS). In addition, individual health authorities (regions, ASLs, AOs, Istituto Superiore di Sanità, etc.) have their own information systems, and the Italian National Statistical Institute, too, produces e-health indicators for the information system Health for all - Italia (Loghi and D'Errico 2012). Apart from administrative data, e-health indicators are also calculated on the basis of specific surveys. The following are some of the most important surveys on different aspects of e-health, which, to our knowledge, were carried out in Italy prior to In 2002 Ce.Ri.S.Ma.S. (Centre for Research and Studies on Health Management) conducted the Health.Net survey to find out about the number of Italian health centres on the Internet. The survey regarded public and private health facilities located throughout the country. The results showed that in 2002 fewer than one centre in two was on the Internet (47%) and, even in the case of those that were, their websites often lacked important structural features (sitemap, internal search engine, foreign language version) (Baraldi and Memmola 2003). Again in 2002 Confservizi promoted a survey to find out about the spread of ICT in health care. The results of this survey show that almost all health centres declared a percentage of spending on ICT that was less than 1%: in particular, 93% of centres had their own website, 40% had set up a call centre, 24% had activated a web contact, one centre said it used a CRM application (Customer Relationship Management). As regards Internet connections, in % of health centres had a 8

9 broadband internet connection, while 13.6% planned to have one within 12 months (Rossi Mori 2002). In 2008 Confindustria carried out a survey of local health authorities, health centres and private nursing homes to make a quantitative assessment of e-health in Italy (Confindustria 2009). The survey was later repeated using a wider sample and an online survey of ASLs and AOs. Most recent data show that in 2010 the regions with the best performance in terms of availability of online health services were Lombardy, Emilia Romagna and the autonomous province of Trento (Between 2010). In 2009, as part of the LITIS project (Levels of Technological Innovations in Health) promoted by Federsanità-ANCI and ForumPA, a survey was carried out on health centres to acquire data for the purpose of developing a methodology to evaluate technological innovation. This is one of the most comprehensive surveys on the subject (Rossi Mori and Tamburis 2010). In 2010, as part of a project involving the Ministry of Health and La Sapienza University of Rome (2010), a survey was carried out to identify the needs of citizens as regards online information on protection, promotion of health and health care. The results show that GPs were the first source of information for health problems, followed by the Internet, especially through the use of search engines. Respondents perceived a need to be informed about various aspects of their health and there was widespread interest in the publication on the Internet of campaigns to promote health (e.g. blood and/or organ donations, occupational safety, responsible use of medicine, etc), healthy lifestyles and national health services, highlighting the great information potential of the Internet. As of 2008 the ICT in health observatory of the Politecnico of Milan has been carrying out surveys to understand the evolution and priorities of ICT investment in health facilities and to analyze differences among Italian regions. Questionnaires were given to CIOs (Chief Information Officers), and general, administrative and health managers. This is one of the most significant Italian surveys for e-health assessment, especially because of the frequency and regularity with which it is conducted, so that trends in the evolution of the phenomenon in Italian regions over time can be followed (Observatory of the Politecnico of Milan, 2011). We should stress, however, that in general health sector surveys, including those mentioned, suffer from high levels of non-response and partial response. Overall, the results of these surveys, carried out independently and for different purposes, indicate that innovation in healthcare in Italy is still fragmentary. Surveys are usually carried out without 9

10 meeting the quality criteria of public statistics 8 (Eurostat 2003) and use different definitions of variables and classifications, they are not repeated at predetermined intervals and do not always guarantee up-to-date, reliable and comparable information. In addition to the surveys, information systems are also a good source of data, allowing us to integrate, link and compare data from different health authorities at local, regional, national and, last but not least, European levels. However, metadata are sometimes not provided; datasets are not always updated, harmonized and generalized and are rarely made available to the scientific community for study and research (Rossi Mori and Consorti 2002). Among electronic health initiatives the EHR is an information source of great potential, which can be used for purposes of health management policies and the protection and promotion of health. In fact, it stores information about the course of a person s life, the demographic and social characteristics of citizens (age, place of birth, marital status, education and employment status), the clinical history of a person, the treatment and care they have received. For doctors, epidemiologists and researchers the EHR is a wealth of information on which to conduct studies on the state of health of the population over time, the risk factors, the effectiveness of therapies, the outcome of treatments. For doctors, the EHR is a tool that can help them in their decisions; for epidemiologists it is an ideal tool for the study of the health of a population, lifestyles, the use of health services, because it allows to follow individuals over time, and to understand if and which, changes in health are associated with changes in lifestyle, taking medication and exposure to risk factors over time. 4. Data, methods and research hypotheses The aim of this work is to assess the extent to which e-health has been implemented in the Italian health system through an analysis of data of the LITIS survey (Levels of Technological Innovation in Health), promoted and funded by Federsanità-ANCI in The aim of the survey was to produce and validate an instrument for measuring the implementation of e-health and to assist decision makers in the governance of the phenomenon at national level. The survey was conducted in collaboration with the Department of Innovation of the Presidency of the Council of Ministers and FORUM PA, with the National Research Council providing methodological support. In particular, the survey focused on: functions, i.e. services/information accessible to different categories of stakeholders (citizens, doctors and other social-health staff, managers, administrative staff), indirect components (which are a prerequisite for the implementation of the functions, and 8 Criteria for data quality are: comparability, relevance, accuracy, responsiveness, accessibility and clarity, consistency (Eurostat 2003). 10

11 the governance of change, but which do not, per se, provide services to the stakeholders) (Tamburis et al., 2011, Forum PA 2011). The survey involved administering a questionnaire to ASLs and public and private AOs throughout the country. The most numerous set of variables regarded the implementation, use and spread of e- health initiatives (functions); followed by a series of questions on governance and on implemented or future e-health plans (indirect components); other variables concerned structural characteristics (number of inhabitants, number of beds, number of outpatient services, total annual expenditure, ICT expenditure, number and cost of ICT workers). The variables are mostly quantitative and regarded the year Of the 254 health care centres in Italy in 2010, 147 answered the questionnaire (Forum PA 2011) with a response rate of almost 60% (very high for surveys in the health field). The most highly represented regions in the sample were Lombardy with 23 facilities, Campania with 20 facilities and Sicily with 17 facilities. Certain regions are poorly represented (e.g. Puglia is represented by only one facility), while others are completely absent (Basilicata, Molise, Valle d'aosta, Marche). Although the results are not representative of the entire Italian health system, the LITIS survey is one of the most significant experience so far conducted in Italy for the evaluation of e-health, in terms of both the number and detail of information and the response rate. The information provided by LITIS constitutes a valuable source of data on e-health. The analysis of this data source, therefore, is a strength of this work. In this paper, we carry out an exploratory multidimensional analysis (Principal Component Analysis - PCA) to assess the existence of significant associations among variables concerning the development, structure and governance of e-health. These associations will then allow to assess which structural features (for example, high number of ICT workers, expenditure per ICT worker) are associated with a high level of e-health development and if a high level of ICT implementation is indeed accompanied by a strategy for e-health development. PCA gives a snapshot of the data and, being an exploratory methodology, does not assume causal relationships between the variables 9. In addition, the cross-sectional nature of the data does not allow for an interpretation of the results in terms of cause-effect relationships. In this paper PCA aims to identify snapshots that describe the e-health characteristics of health facilities in the sample through a set of variables chosen a priori by the researcher. The selection of active variables was based on the evaluation model proposed by Di Carlo and Santarelli (2012), in 9 For a detailed description of PCA see the methodological appendix. 11

12 which e-health is divided into the following main dimensions: demand and supply of services, technological training of health personnel, IT network. Active variables chosen to analyze the data include: as regard supply, the percentage of electronic payments, bookings, digital withdrawal of results 10 out of the total, availability of the EHR(yes/no), access to health information on the web and telemedicine; as regards the use of digital services, quantitative variables expressing the percentage use of the above services by citizens; as regards training and skills, the proportion of staff that give out digital certificates and digital prescriptions, do training courses in technology and clinical communication; finally, as regards networking (i.e. the capacity of health centres to act as part of a single system) the percentage of GPs and pediatricians connected to regional networks and other networks, the number of ways in which data is exchanged and shared among doctors and how the treatment cycle is managed and shared among operators (digital signature, bar code, etc). The variables listed are all quantitative and expressed in different units of measure 11. For example, as regards the implementation of electronic systems of payment the figures refer to the percentage of electronic payments out of the total number of payments. As regards health information on the web, figures refer to the number of types of information on the health centre s portal. Table 1 details the active variables. Table 1: PCA active variables. Dimension Supply (S) Use (U) Variables % of electronic methods of payment available out of the total number of methods of payment % of electronic methods of booking appointments out of the total % of electronic methods of results withdrawal out of the total implementation of EHR(yes/no) average number of types of information about health services provided by the portal and the PRO (Public Relations Office) number of telemedicine typologies implemented % of digital payments made out of the total payments % of digital bookings made out of the total bookings % of digital withdrawals of results out of the total % of patients who had an EHRin 2009 % of use of the web portal and PRO out of the total number of communication methods (web portal, PRO, information desks, contact centres, other) 10 In this work, the terms electronic and digital are used indistinctly to refer services implemented via phone, mobile phone, the Internet, , i-pad/i-phone/smart phone, etc, i.e. through the general application of ICT. 11 The software used for PCA (Spad) automatically standardizes all variables. 12

13 Training (T) Networking (N) % of patients who received telemedicine services out of the total number of patients average % of GPs and paediatricians in the centre that provide digital certificates average % of GPs and paediatricians in the centre that give out electronic prescriptions number of ICT literacy and refresher courses for health personnel provided by the centre % of GPs and paediatricians connected to the regional network and other networks number of ways in which data is exchanged and shared among doctors number of ICT infrastructures in pharmacies for the management and sharing of therapeutic cycles (digital signature, bar code, etc) Taking into account the above considerations on the implementation of e-health in Italy, we expect a higher level of e-health development associated with a wide range of services that are extensively offered to and used by citizens. We also expect a picture of e-health characterized by stand-alone initiatives without any harmonization of aims. In particular, we would expect the network dimension to be less developed than the other three dimensions of the model described. Moreover, we would expect the North to have the most developed health network and the South the least. With regard to planning we expect a higher level of e-health development to be accompanied by explicit governance plans and actions that are commonly put into practice to promote the participation of operators and citizens in e-health initiatives. Specifically, we assume that the level of e-health is more developed in facilities where spending is higher on ICT products, services and personnel (both internal and external). Our hypotheses are verified in the next section which presents the results of the empirical analysis. 5. Results In this paper we aim to explore associations among the features of the e-health services provided by the health centres of the LITIS sample by means of PCA. Figure 1 shows the factorial plane of the PCA. Comments on the results refer to the factorial plane formed by the first two axes, since the amount of information provided by successive planes is poor and, therefore, negligible. 13

14 Active variables are all placed on the left side of the plane except the one relating to the use of electronic payments; health centres are characterized by a significant supply of services and staff training. The variables that describe the network within the local/regional systems also strongly characterize the sample, while those relating to the use of electronic services are unrepresentative. Specifically, the first component (the x-axis) shows a strong positive correlation between the levels of supply of digital services (measured by variables concerning the provision of electronic bookings, telemedicine, withdrawal of results) and IT network (particularly among GPs and paediatricians). We can define this component in terms of supply of digital services and networking among facilities. The second component (the y-axis) has a strong correlation with the supply of digital services (electronic bookings, telemedicine, EHR) and indicators on staff training. We can then define this second component as supply of digital services and ICT training of health personnel. The factorial plane clearly shows a low correspondence between the implementation of electronic services and their use by citizens. In fact, just to mention an example, a high level of supply of electronic withdrawals of results does correspond to an equally high level of use. This distinction between supply and use of services does not seem to exists, instead, for the EHR; that is if the EHR is implemented then it is also used. However, previous studies (e.g. Forum PA 2011, Tamburis et al. 2011) show that, although the technological infrastructure for EHR is at an advanced state of implementation in many national health centres, citizens almost never use it. The result suggests, therefore, that questions about the use of EHR have been misinterpreted by respondents. In this regard, it should be made clear that an e-health questionnaire should be completed by more than one respondent, each for their area of responsibility. Indeed, the phenomenon of e-health, being multidimensional, is made up of several aspects that are usually under the responsibility of different professionals. For example, communication and exchange of data among doctors and health care professionals can be properly assessed by them, while the level of web-based communication can be ascertained by those who manage and update the centre s website. Again, taking this into account we may reasonably conclude that the question about using the EHR has been misinterpreted by respondents and therefore the result is to be considered void. The wealth of digital services is closely linked to the onset of a spontaneous market that flourishes thanks to the initiatives of the most innovative local health centres. These centres follow the socalled copernican approach, in which health plans at local, regional and national level are central to governance actions. Centres that use the copernican approach assess demand for health and respond by producing explicit and shared action plans for the governance of e-health. Such plans 14

15 involve changes in organization, processes and human resource management, as well as the widespread adoption of ICT. The decoupling of supply and use of services (which also exists in other areas of ICT application, for example, e-commerce) is to be considered one of the consequences of the lack of sensitivity of policy makers towards technological innovation in health care. The factorial plane shows that in-house networks (communication networks among physicians, paediatricians, pharmacies of a single centre) are more developed than regional networks (which mainly consist of common and interoperable information systems among centres in the same region). The results confirm our expectations: in our country the e-health network is developing through autonomous initiatives that are not harmonized at either the regional or local level. Staff skills (the ability to use the new technologies) and training (computer literacy initiatives and technology refresher courses for staff) are two components that have been analysed by the LITIS survey. The ability to handle digital certificates and prescriptions does not seem to be linked to other electronic skills; they seem to have been acquired by individual initiative rather than through the training opportunities offered by the centres. Literacy initiatives and refresher courses are typical of the spontaneous market previously mentioned and are usually organized by centres that adopt the copernican approach. The results show that there is a strong correlation between the adoption of initiatives for the training of health personnel and the implementation of electronic health services, particularly telemedicine, electronic withdrawal of results and online communication. The positive association between 'digital' training for the staff and the use of e-health services is well documented in literature (Rossi Mori 2004, Rossi Mori and Consorti 2002). Both depend on the explicit planning of digital healthcare and require a cultural awareness of the benefits of ICT in health care. To date both health administrators and policy makers are still slow to collaborate and share experiences in health care processes (Rossi Mori et al. 2012). The picture generated by PCA confirms that the dimensions identified by the authors in their theoretical model (Di Carlo and Santarelli2012) are effectively distinct: in particular, services supply appears to be much more developed than service use. This decoupling may be caused by the lack of communication between health centres and citizens. In fact, PCA shows that the sample is scarcely characterized by online communication, which could mean a lack of information on the web or simply poor promotion of information channels. Low use of the web and other applications providing information about health services may also be related to a low level of computer literacy, especially among the elderly who constitute the largest proportion of health service users. 15

16 On the one hand, the results confirm that strong e-health development is usually coupled with initiatives to inculcate a culture of the use of new technologies both among users and among health care staff. On the other hand, as amply shown in literature, it is difficult to disseminate innovation in the health sector, and not only in Italy. To quote Berwick (2003: 1969): in health care, invention is hard, but dissemination is even harder. A set of illustrative variables is projected on the plan originated by the active variables to assess how some of the characteristics of health centres relate to the e-health characteristics expressed by the active variables. Table 2 shows the illustrative variables 12. Table 2: PCA illustrative variables. Illustrative Variables region geographical area (North West, North East, Centre, South, Islands) health centre typology (ASL, AO, PU 13, IRCCS 14 ) number of employees (4 classes of increasingly greater numbers: 1, 2, 3, 4) number of hospital beds number of outpatients number of ICT workers (4 classes of increasingly greater numbers: 1, 2, 3, 4) expenditure per ICT worker in 2008 (4 classes of increasingly greater values: 1, 2, 3, 4) expenditure per ICT contract (4 classes of increasingly greater values: 1, 2, 3, 4) total expenditure in 2008 (4 classes of increasingly greater values: 1, 2, 3, 4) if the centre has an explicit e-health plan (yes/no) if measures have been put in place to promote the participation of operators and citizens in e health initiatives (yes/no) Among the illustrative variables, region, geographical area of residence and health centre type were firstly projected (see Figure 3). The North East and North West of the country are the areas where the e-health is most developed, the Centre and the Islands are in the middle (Sicily and Sardinia are in different positions), while the South is the area that is most behind. The distribution of the regions is not homogeneous in terms of geographic area (for example, Abruzzo and Liguria are in positions that do not correspond to their respective areas). Friuli Venezia Giulia and Puglia are also atypical, due to the low number of centres surveyed for these regions. Other poorly represented regions are Trentino Alto Adige (only two centres) and Umbria (three centres). In general, it can be 12 For details of some illustrative variables, see the methodological appendix. 13 University general hospital. 14 Institutes for research, hospitalization and care. 16

17 said that geographical area distribution reflects the distribution of e-health development as is found in literature (Forum PA 2011), with the North East being the most developed area, followed by the North West, Centre, South and the Islands. No conclusions can be reached in terms of regions because some are poorly represented. On the whole, the picture that emerges reflects the lack of harmonization in e-health development in the regions as evidenced in literature (Rossi Mori and Tamburis 2010, Tamburis et al. 2011) and as we expected. The governance of the phenomenon is left, in fact, to the initiatives of individual centres and suffers from a lack of coordination at the regional level and a lack of guidelines at the central level. Finally, there is no great difference between ASLs, AOs, IRCCSs or PUs in terms of e-health implementation (all of them are around average). Figure 4 shows the plane of the illustrative variables on the number of workers (total and ICT) and expenditure (total and ICT). Numeric variables on the number of employees and ICT workers and expenditure are not closely associated with the level of e-health development, although higher ICT expenditure and more ICT personnel can be found in the most technologically developed centres (see Figure 4). The results show that the implementation of a wide range of electronic services is positively but not closely linked to the financial and human resources available. However, in interpreting these results it should be remembered that there was a high rate of non-response as regards the variables on expenditure and in some cases the responses appear to be unreliable. It should also be mentioned that the quality of data on expenditure is generally low in health surveys, especially in regions subject to ministerial repayment plans. These results seem to confirm that, in the development of e-health, a culture oriented to efficiency counts more than financial resources. Similar considerations apply to data on the number of ICT workers, which are greatly affected by how an ICT worker is defined. The questionnaire did not include a glossary and, therefore, the respondents may differ in their interpretations. In fact, there is no official classification for health personnel let alone one for ICT service providers (on this subject see Burgio et al. 2011). Finally, the variables expressing whether a centre has an explicit e-health plan and if measures have been put in place to promote the participation of operators and the public in e-health initiatives are projected, together with variables on the number of beds and annual outpatients (Figure 5). As expected, the phenomenon is more developed where there is medium to long term planning and governance. The variables on e-health policies and governance are the structural components mentioned in section 4, which represent the environmental, cultural and procedural conditions most closely linked to technological innovation and e-health. These play an essential part in the evaluation of the state of e-health development of a health centre. Recent studies indicate that 17

18 national and regional toolkits based on the indirect components could be produced in future to support planning and evaluation (Tamburis et al. 2011). 6. Conclusions In Italy in recent years ICT has spread to all key health processes, clinical and administrative, playing an increasingly central and strategic role in supporting operational and governance aspects of health facilities (Osservatorio Politecnico of Milan 2011). State of the art initiatives in the use of ICT in health care can be found in individual health centres and at regional level. Yet overall, there is still no real understanding of the innovative contribution that ICT can make in terms of both the organization of health facilities and the quality of life for citizens. The development of e-health in Italy, therefore, is not systematic but pervaded by localisms. It is to be hoped that a more consistent and systematic governance can be developed within a framework of structural measures based on accurate and up-to-date data. At present, there is a paucity of data in Italy in the field of e-health and even where present they are not always up-to-date, comparable and reliable. This paper has set itself two goals: firstly, to review the e-health data and statistical surveys currently available in Italy; then, study the characteristics of e-health by analyzing data from the 2009 LITIS survey. Because of the complexity of the e-health phenomenon we decided to use a series of quantitative indicators based on literature and the availability of survey variables. In selecting the variables the model put forward by the authors has been used according to which the phenomenon of e-health can best be studied by dividing it into four dimensions: supply, use, staff training and network (Di Carlo and Santarelli 2012). The results reveal that supply and use of health services are decoupled and give a mixed picture as regards digital initiatives, which are rarely systematic in nature. Moreover, it seems that the development of e-health is very different in the North, Centre and the South. The North seems to have more shared governance plans within health centres and the use of electronic services seems to be more advanced. This may be due to a greater awareness of the innovative potential of ICT and a culture among health policy makers oriented towards reasoned and structured programmes. Similar research in Europe has shown that the success of e-health is strongly linked to policy objectives. There is a need for clear planning objectives also in small-scale interventions if these are to be effective (Ronchi 2012). Furthermore, the results show that there is no link between one specific type of centre and a high level of e-health development; nor does it seem that the level of e-health is associated to expenditure or the number of ICT workers. 18

19 The quality of LITIS data analyzed in this work is not optimal due to a number of problems that are often encountered in health care research, as we discussed in Section 4. However, the LITIS project should be seen as one of the most valuable survey on e-health in Italy, in terms of both the objectives set, and partial and total response rate. Good e-health planning can benefit from such experiences and it is to be hoped they can be replicated and standardized in future. In this regard, e- health surveys should be carried out regularly, to produce statistics in line with the OECD model survey. Availability of standardized and comparable data on facilities, regions and the central bodies of the health system can be used for quantitative and replicable analyses to measure the readiness of health centres, the state of implementation and use of e-services, the evolution of the phenomenon over time, health system efficiency and improvements in the quality of citizens lives. Only with a solid understanding of e-health will it be possible to plan development systematically and efficiently for the benefit of society as a whole. 19

20 Figure 2: Active variables on the factorial plane, LITIS

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