Electronic Health (E Health) provides both opportunities and challenges for the redesigning of economic and service structures in terms of both production and information worldwide. Therefore, it is no surprising that many European countries are implementing E Health processes. These processes are strictly linked to ICTs [Marino, Pariso, 2019, 2020], and one of the main goals is to ensure the creation of the continuous value in health (Squitieri, et al, 2017; Zhao, et al, 2019). Following this research stream, it is strategic to ensure and activate E Health tools, because it could allow to maintain and add to creation of value in health as in the case of public services (i.e health, education, national and local services). The research, in this study, is focused on E Health tools with particular reference to ICTs diffusion and how these two factors affect Italian Health to create value in the health public sector. These actions are strictly linked to how Italian government operates at micro and macro level using ICT (Bloom, et al, 2019). Since the complexity of service delivery increases over the years as the expectation for transparency of the citizen part, especially in a sector with high technological innovation level (Ash, 1997; Gardner, et al. 2007; Hwang & Christensen, 2008; Lehoux, et al. 2019;), recent studies highlighted the original character of the E Health and how a government should realize value in health (Eysenbach, & Jadad, 2001; Oh, H., Rizo, et al. 2005; van Gemert-Pijnen, et al. 2011; Benjamin, et al. 2019). It is interesting to note that, these studies are in line with other conceptual research in which it emerged that the creation of PVs requires to work in alignment, coordination, and co-creation. Creating PVs means changing the programs of public departments. These changes, have been implemented in many Countries and have produced interesting value in health (Norman, & Skinner, 2006;K elly, et al. 2019; Casado-Vara, & Corchado, 2019). Such changes, are related to communication, coordination and integration of departments with reference to the new services delivered. These actions and decisions highlight the necessity to negotiate procedures and to reorganize budget and department employees. A recent study argues that these processes are functional to generating positive value in health (Iqbal, et al. 2019; Porter, & Kramer, 2019; Urena, et al. 2019; Finkelstein, et al. 2019). The governments are operating in a continuously changing context. According to the literature (O'Flynn, 2007; Williams & Shearer 2011; Chohan, 2019;) conceptualizations of public value the government can improve the collective and individual service delivery (Besley & Ghatak, 2007; Romzek, et al., 2014). In this sense, the output of a government is aimed at improving public value as a collective goal. Public value means that, public interest and common good should be the main concern of the public sector. It is interesting to note that this approach considers the citizens as effective stakeholders in the process of public value in health creation (Bryson, et al., 2014; Mintrom & Luetjens, 2017; Cluley & Radnor 2020). The citizens can determinate a higher level of democracy and legitimate the government, within of two processes of democracy: bottom up and top down. Furthermore, the ICTs are strategic drivers for the enhancement of public value in health. They may be fundamental tools in the processes’ optimization to increase the stakeholders’ engagement by including also the employees in a network governance logic. In fact, the governments might have to manage and to deliver information, services and gain legitimization in an interactional logic with stakeholders. In this context, ICTs can propose new ideas and models of service delivery. There are interesting contributions that consider ICTs as enabling factors to create public value in health. (Martins, et al., 2019; Ferlie,et al., 2019; Cronemberger & Gil-Garcia, 2019; Twizeyimana, & Andersson, 2019). For example, E Health can contribute by improving efficiency and introducing innovation in the delivery of services, by enriching hospital - patient relationships with employees, and by strengthening trust in and support for and legitimacy of health organizations (Miller, et al.,1997; Palanisamy & Thirunavukarasu, 2019). Following this research stream, E Health is an enabling factor to empower hospital, patient, health service and support inclusive practices especially for the differently process at the national and local level (Krebs, & Duncan, 2015; Cooper, et al., 2019;). Furthermore, recent studies highlight the potential of ICTs in creating value in health, by enhancing ICTs-relations for the assessment of and intra-hospital services, which produce added value in health. It is interesting to note the different approaches of value in health, Porter (2010, pag 2) argues that: “Value is measured by outputs, not inputs. Hence value in health care depends on the actual patient health outcomes, not the volume of services delivered. More care is not always better care, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care utilized; process measurement and improvements are important tactics but no substitutes for measuring outcomes and costs”. Following this definition, Mosadeghrad (2013, pag 1), proposes a different definition: based on "consistently delighting the patient by providing efficacious, effective and efficient healthcare services according to the latest clinical guidelines and standards, which meet the patient's needs and satisfies providers". The evolution of these studies, related to value E Health are in Campanella et al. (2016), with special reference to Electronic Health Record (EHR) and one of the results shows that EHR systems can improve the value in health. In fact, with reference to the value in health and EHR, Maya et al. (2020) in the conclusion of their paper, argued that “linking individuals’ health records with their data-derived family history has untapped potential for supporting diagnostic and clinical decision-making”. The studies based on EHR, point out that each public hospital should promote more interactive and active contributions to decision making through timely sharing of information and communication. The result of this process is that ICT would contribute to the creation of value in health by improving hospitals action in terms of value and transparency of public services. All these positive elements present a weakness linked to decision making process between professional instance (medical, nursing, technological) and choices of the public health service (Adler-et al., 2015; Desautels, et al., 2016; Tavares, & Oliveira, 2016). On the one hand, the issue of the assessment of the value in health provision delivers has become strategic over the last few years. On the other hand, governments need guarantee transparency and encourage stakeholder a collaborative participation. In line with these concepts, some studies focused on specific applications to create value in health sector (Graber, et al., 2019; Kruse, et al., 2016). In recent period, February 2020, E health and EHR have been considered strategic assets also in response to the health emergency of the Covid-19. In this context, in order to create an effective balance between value of health service and lockdown, the European countries are turning to a massive use of the E Health. The level of E Health diffusion also represents the extent to which each country is operating in the development, effectiveness, and efficiency of both human and economic advancement. This development process involves the creation of culture (Lepore et al., 2018), investments in network building by including both in the public and private field several sectors (i.e. education, health, economies) at different levels (i.e service delivery, production process). In this context, it is fundamental for the European countries to be able to implement the processes of diffusing and integrating E Health within their societies to translate the benefits in to economic development (European Policy E Health, 2020). The divergence in E Health accessibility and disparity of digital opportunities within European country, with a different distribution among its hospitals, may create bottlenecks to develop value in health. Although, this phenomenon has had a tendency to contract, it is still a critical issue for many European countries (Tuikka, et al., 2016; Grossman, et al., 2016; Bonomi, 2016). The E Health is in close correlation with EHR implementation and use, in fact the chance to efficiently access to this tool represents on the one hand the countries' ability to provide innovative digital services through adequate infrastructures, and, on the other, to guarantee all patients, full access to the opportunities offered by E Health tools. Italy shows a different degree of E Health and EHR implementation and use, within its territory with great differences between the regions. This issue represents an important bottleneck in order to develop E Health. This study assesses EHR diffusion and adoption across Italian southern cities and elaborates the framework of E Health in order evaluate the different degree of digital health present in Italian southern cities and can help to understand how this issue may develop Italian health services. The present analysis will be of interest to researchers, policy makers and government planners, who can acquire information for the development of national E Health strategies. The paper is organized as follows: section two outlines a conceptual background on the E Health and EHR. Section 3 shows the methodology and Sect. 4 displays the results and related discussion with reference to the Italian experience. Finally, Sect. 5 shows the conclusions of the paper.
The studies on the EHR, starting from a technological point of view, highlight the strategic role of ICT and the extent of the missed opportunities when they are not exploited. Moreover, the EHR is linked to a gap identified as a social issue in particular between the European countries (Katehakis, et al., 2011; McGinn, et al. 2011; Emmanouilidou, & Burke, 2013). In line with this point of view, EHRs were first linked to ICT access, then also to E Health access, and only later to the development of the information society (Al Aswad et al., 2013; Coorevits, et al., 2013; Nguyen, et al., 2014). These studies represented a critical literature review of some studies to the means of electronic health records by analyzing the advantages and disadvantages from different perspectives and viewpoints related to EHR. The main perspectives of these studies are related to the adoption of electronic health records in different European countries in order to trace out the current status of adopting this technology. These studies highlighted the importance of adoption of electronic health records and the differences among the European countries. The relevant outcomes are linked to the critical points related to the no adoption of EHR. These critical points are related to the organizational, technological and managerial gaps and they concerned national and local health services and nevertheless, the absence of the one European Health Service. However, these studies followed a critical review method of the adoption of EHR starting by its implementation in the European countries. They highlighted that, at organizational level, the critical points are ,on the one hand, linked to the organizations’ need to implement ICT in order to effect the changes, and, on the other hand, linked to the insufficient attention of the current culture and procedures to the change goals. In fact, this issue within hospitals, their services’ delivery, and medical culture have been analyzed and studied (Strong, et al., 2014; Kazley & Ozcan 2007). The ICT impact is at multilevel in the organizational change process, and its success, within hospitals, depends on the capability to the management, access, use, and reuse of the informations (Buntin, et al., 2011; Miriovsky, et al., 2012;). The organizational and technological level, should be supported by managerial ones. At managerial level, the studies cited above, suggest that management provides medical ICT training pay attention to it, as strategic outcome. Infact, if this training will done ineffectively can increase managerial risks (Terry, et al., 2008). These variables, linked to organizational, technological and managerial tools, are important to support the hospital information systems. These three approaches, determines an important step forward in assessment of the EHR because, it is associated with the efficient usage as well as information access. These studies were, always, limited and not strongly linked to both pathology and cities context in which there are strategic hospitals that deliver health services. Only in recent years, the literature developed studies in this research line and in Europe less than at worldwide level (Aldosari, 2017; Fukami, & Masuda, 2019; Joukes, et al., 2019; Martel, et al., 2018; Saleem, & Herout, J 2018;). In line with this assumption, it is important for the future of Italian health service, to develop studies in relation with the adoption of EHR because recent reforms assign a central role to the strategic hospitals of the city to implement public health policies. The reform, proposed by central government, must be implemented at local level. In this framework, the Public Administration is the main actor in the implementation of EHR activity (Bonacina, et al., 2011; Fernández-Cardeñosa, et al. 2012; Bonomi, et al., 2015;). In this context, the reform is more complex than the E Health as a technological, organizational and managerial issue, by evolving in relation to the concept of the information society. The EHR is studied as an Italian global issue from North to South with tactical decisions to make in all cities where there are strategic hospitals. The pillars related to EHR adoption are three: care, research and governance. Firstly, the care is related to prevention, diagnosis, treatment and rehabilitation. The aim of this pillar is to sustain the Local-Health Service that take care of the patient by means of the Institutions of the National Health Service. Secondly, the research, related to the medical, biomedical and epidemiological sectors. The aim of this pillar is to deliver economic resources within their respective responsibilities assigned by law by means of National Health. Thirdly, the governance linked to the quality of care and evaluation of health care in order to assess organizational, technological and managerial issues. The aims are to coordinate, integrate and control the Local Health Service within their respective responsibilities assigned by law. The debate, linked to HER, within cities with strategic hospitals, highlights the different roles of innovation: organizational, financial, operative (process and service delivery), management, managerial and technological. These are useful for the decision making process of each city’s government to establish the course of action to be undertaken in order to improve the public value of Local Health Service. Currently the Covid-19 emergency forces many countries to strengthen the ICT adoption and invest in this way in E Health. For instance, a large part of Italy, particularly the southern Italian experience (Marino, Pariso 2019) but also in other European Countries (Kyriakidou, Michalakelis, & Sphicopoulos, 2011, Ruiz-Rodríguez, Lucendo-Monedero, & González-Relaño, 2018, Billari, Giuntella, & Stella, L. 2019) are characterized by very few opportunities for an innovative action related to ICT adoption in E Health. It is interesting to note that Italian government underlines the importance of better performance related to National Health Service through the capacity to utilize the opportunities created by E Health in terms of dissemination of information and knowledge in order to improve individual and collective choices. At Italian local level, regions and cities, in the past and recently, pointed out that the different level of the cities' E Health widely mirror access and diffusion disparities in ICTs. In many Italian cities, large portions of the population are out of the information society network and run the risk of becoming outcasts. Governments should aim at removing disparities, linked to existing access inequalities. Governments should focus on reform of the public national health service in which the E Health and EHR are strategic bottlenecks which hinder the access to the communication between patients and health. In this logic, if governments wants to implement EHR they need to shed the role of service provider supervision, create favorable conditions, and take actions to ensure equal opportunities for all. This is the design of inclusion. A new frame of mind focused on inclusion is required, and particularly in the Italian southern cities. In Italy, there are still many actions to implement aimed at bridging the E Health and HER (Osservatorio Salute 2018). Will it be possible? In the next section, methodology deals with the approach to adopted to answer the question. Moreover, Sect. 3 and 4 display the results and related discussion and, finally, Sect. 5 shows the conclusions of the paper.