Collaborative governance for longitudinal healthcare services: enabling conditions and leading practices

Coordination has to do with the linking together of organizations, managing the interdependencies among them (Malone and Crowston, 1994; Longest and Klingensmith, 1997). In healthcare, coordination is influenced by the complex nature of the system as well as by the plurality of actors involved. In particular, the most cited determinants of complexity include the opposing interests of stakeholders, the division of labor in the different levels of governments, the active role of private parties such as providers, insurance and pharmaceutical companies, and private regulatory organizations (Field, 2008). In such a context, coordination mechanisms are subject to vertical influence by the institutional frameworks adopted at country level in order to govern the healthcare system as well as by all the actors taking part in the policy process. Horizontally, all the healthcare providers and stakeholders that play an active part in healthcare processes are actors in the system. The paper analyses practices in terms of coordination (Bouckaert et al., 2010 and Ongaro, 2009) and discusses the introduction of a regional healthcare information system supporting the creation of Electronic Patient Records (EPR) in the Italian regions of Lombardy and Veneto. The EPR is a longitudinal electronic record of a patient’s healthcare history. This is in itself a coordinating tool for healthcare providers. Whilst the ultimate impact of an EPR may be disputable, it is usually considered as being potentially extremely beneficial for the improvement of healthcare services in terms of their quality, effectiveness and possibly efficiency. The purpose of this paper is to depict the coordination and governance mechanisms that have emerged during the implementation process of an EPR system at regional level in two separate contexts, and aims to describe the main characteristics of the project in order to explore and analyze it. The adoption of a shared information system linking the multiple providers involved in the delivery of healthcare processes to a patient throughout their life is considered fundamental in order to ensure continuity of care and enhance the effectiveness of healthcare systems by means of more integrated processes (Askim et al., 2011; Ongaro, 2004). At the basis of such a system is the creation of a life-long electronic patient record that embeds any relevant events and information linked to a patient’s healthcare history. Since this process affects many stakeholders and variety of interests of the different players, it represents a complex policy and process innovation that requires great effort for its coordination. The paper is organized as follows: we first examine the relevant literature in order to define a theoretical framework for our analysis before providing a short description of the methodology adopted. We then present the cases, giving a brief background of the Italian Healthcare System and the reforms that have affected it in recent decades. We subsequently focus on the contexts in our analysis (i.e. the Italian regions of Lombardy and Veneto) and illustrate the coordination practices employed during the setting up of their EPR systems, discussing the mechanisms put in place to implement it and drawing some indications about the enabling conditions and the lessons learnt.