Italy’s National Healthcare System and eHealth Landscape: A Multilayered System of Health and Digital Health Services

Italy’s National Healthcare System and eHealth Landscape: A Multilayered System of Health and Digital Health Services | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 15 April 2025 V1 Latest version Share on Italy’s National Healthcare System and eHealth Landscape: A Multilayered System of Health and Digital Health Services Author : Alessandro Giovanni Vincenzo Napoli 0009-0007-0699-2476 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174475411.13465851/v1 1919 views 283 downloads Contents Abstract Introduction Unpacking the SSN Enhancing the SSN The SSN and eHealth Digitalisation Efforts Satisfaction and Use Conclusion Bibliography: Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Italy's National Healthcare System (Servizio Sanitario Nazionale, SSN) has introduced various reforms and investments to enhance primary care and digital infrastructure, particularly through the National Recovery and Resilience Plan (Piano Nazionale Ripresa Resilienza, PNRR). This paper examines the SSN's multilayered organisational structure, key initiatives, and physical and digital networks, including Care Networks, Hub-Spoke networks, and the Connected Care. These efforts aim to improve healthcare equity, resilience, and access across regions. While navigating the complexities of a decentralised healthcare system presents ongoing challenges, Italy's strategic focus on structural and digital innovation signals a clear path toward a more modern and accessible national health service. Introduction Italy has recently begun introducing various reforms and initiatives to strengthen its primary and community healthcare, upgrade its digital health infrastructure, and modernise hospital networks throughout the country. The Italian National Recovery and Resistance Plan (Piano Nazionale Ripresa Resilienza, PNRR) has significantly boosted these initiatives, allocating over €15.62 billion between 2021 and 2026 toward healthcare initiatives (Ministero della Salute, 2024a). The decentralised nature of the Italian National Healthcare System (Servizio Sanitario Nazionale, SSN) presents challenges and disparities between regions, making it difficult to deliver the equitable, universal healthcare it intends to provide. Despite this, the SSN delivers adequate essential care across its regions thanks to the current and ongoing reforms that address regional disparities and enhance resilience. This paper examines the SSN and how various digital reforms and organisational structures have shaped the healthcare system, bringing new challenges and opportunities to access healthcare and healthcare information. Unpacking the organisational structure and funding mechanisms will provide a clear overview of the current SSN and lay the foundation for understanding how recent initiatives, reforms, and increased financial resources have impacted the healthcare system, as well as how the Italian population is being supplied and can access healthcare in the digital era. The objective of this paper is not to provide a comprehensive breakdown of all the elements of the SSN, but rather to provide an overview of its key interconnected components and the digitalisation efforts aimed at enhancing them. This paper offers some insight into the layers of operational structures, mechanisms and networks using the most recent publicly available data at the time of writing. Unpacking the SSN The Multi-structure system This section provides a high-level overview of the SSN, which will be examined in more detail in subsequent sections. The SSN has a multilevel organisational structure that divides the planning and implementation between the Italian central government and the 21 regions. The central government decides on a national framework for essential levels of care (Livelli Essentiali di Assistenza, LEA) and a national health budget. The system was designed to provide universal coverage and equitable access to healthcare services to all Italian citizens and legal residents. However, ensuring accessibility across all regions has been challenging with Italy’s decentralised governance structure, which delegates significant healthcare management responsibilities to regional authorities in line with the LEA. This balance between central oversight and regional implementation has led to service quality and access variations, particularly between different geographical areas. As healthcare demands grow due to demographic shifts and evolving medical needs (Longo et al. ,2024), the SSN has sought to enhance efficiency and equity through targeted structural and technological innovations. At an operational level, there are two organisational models for service delivery: Care networks and Hub-Spoke (H-S) Networks. These organisational models also vary across regions (Agenzia Nazionale per i Servizi Sanitari Regionali, 2022, 2024). Although these models are designed to ensure efficient and equitable access to healthcare, they differ significantly in structure, purpose, and benefits. It is important to note that healthcare accessibility refers to the patients’ ability to obtain timely and appropriate healthcare services when needed. Accessibility encompasses several critical dimensions, including physical proximity to healthcare facilities and services, affordability, appointment availability, waiting times, and absence of administrative barriers that may impede access to care. The H-S model reorganises healthcare delivery by concentrating specialised medical services in designated Hubs while ensuring broader access to primary and routine care through smaller Spoke facilities (Lee and Porter, 2013). These H-S structures focus on a particular area of healthcare, such as cardiology or neurology. Alternatively, Care Networks aim to provide continuous and comprehensive care to patients who may need it locally, and cover all areas of care according to patient needs. To leverage new digital systems and technologies, the introduction of the Connected Care system integrates health systems and technologies to facilitate more efficient information flows, telemedicine services, and electronic health record interoperability across these two operational systems (Agenzia Nazionale per i Servizi Sanitari Regionali, 2024; Ielo et al., 2024). These developments have addressed some regional disparities, reduced healthcare fragmentation, and expanded access to digital health services. However, challenges related to implementation, funding, technological infrastructure and regional inequalities persist. Such barriers continue to shape the evolution of Italy’s health care system. It is also important to note that different user competencies exist for patients and healthcare providers across technologies and services (Bobini et al., 2023 : 480-484). Before synthesising these elements, the barriers they face and the opportunities they bring, it is essential to unpack the SSN, its organisational structure, and funding mechanisms. What is the SSN: Operational Structure Italy’s SSN was established in 1978 and follows the Beveridge healthcare model, ensuring healthcare as a fundamental right for all citizens and legal residents. It operates as a universal tax-funded system with a decentralised structure, granting regional autonomy. The central government provides funding, establishes regulations, and defines essential levels of care (LEA), which all 21 regions must implement. While decentralisation allows regions to tailor healthcare to local needs, tensions arise between uniform national standards and regional implementation (Ministero della Salute, 2025). The Ministry of Health sets national health priorities, defines the national benefits package (LEA), determines per capita funding with the Ministry of Economy and Finance, and oversees long-term planning. It monitors the SSN, allocates resources, and collaborates with regional health authorities and Institutes for Care and Scientific Research (IRCCS). The SSN follows a three-year health planning process across national, regional, and local levels. Regions adapt national priorities to their socio-epidemiological contexts through Local Health Authorities (ASLs), which manage healthcare services via public and private facilities, including preventive health measures, primary care, and secondary care. General practitioners (GPs) and paediatricians, acting as independent contractors, serve as gatekeepers for higher levels of care, ensuring coordinated service delivery. This multi-tiered structure balances national oversight with regional flexibility, aligning policy implementation with local health needs (Ministero della Salute, 2025; Greco et al., 2024). What is the SSN: Funding Mechanisms In 2022, Italy’s healthcare funding accounted for approximately 9% of its GDP, below the EU average 10.4% for the same year (De Belvis et al. , 2022; Longo et al. ,2024). SSN funding and allocation mechanisms comprise three key areas: the National Health Fund (Fondo Sanitario Nazionale, FSN), regional distribution, and regional top-ups. These funds flow through a multitiered allocation process, beginning with the FSN. The FSN is determined annually through preliminary budgeting, considering macroeconomic indicators and demographic projections. For 2025, the healthcare budget increased from around €134 billion to €136.5 billion, with a planned rise to €141.3 billion by 2027 (Ministero della Salute, 2024b). Once calculated, the FSN is distributed at the regional level and managed by the State-Regions Conference (Conferenza Stato-Regioni), facilitating communication and consensus between national and regional authorities. The regional distribution follows capitation formulas that account for the population structure, epidemiological profiles, and geographic cost variations. Key allocation criteria include: (1) the capitation principle, adjusting for age-related healthcare needs, particularly in older populations; (2) adjustments based on health needs and service complexity, such as chronic disease prevalence; (3) cost differences influenced by geography and socio-economic factors; and (4) the equalisation fund, which ensures equitable access to healthcare services for regions with lower fiscal capacity. The decentralised nature of the SSN means that regional entities must compete for limited public funding. The third mechanism, regional top-ups, allows regions to supplement central financing with up to 3.5% of their total health budget through local taxation if necessary (De Belvis et al. , 2024b; Garattini et al., 2022). This allocation system addresses regional disparities and ensures efficient and equitable nationwide healthcare delivery. However, challenges persist, particularly in public health infrastructure and private healthcare involvement, as highlighted during the COVID-19 pandemic (De Belvis et al. , 2022). What is the SSN: Hospitals in Italy In recent years, public expenditure for hospitals in Italy has gradually increased in response to the growing demand for healthcare services. These are spending on public and SSN-accredited private facilities primarily providing medical, diagnostic, and treatment services, including overnight care from health professionals, specialised lodging, day care, outpatient services, and home healthcare. Between 2012 and 2020, there was an average annual increase of 1,86% of public expenditure for hospitals. A significant increase came in 2020, which saw a rise of 4.8%, seeing public expenditure for hospitals amount to around €73,1 billion and standing at €73,3 billion in 2023 (these are the most up-to-date figures at the time of writing). Despite this rise in spending, there has been a decline in public structures and hospital beds across the country, which will be discussed in more detail in the following section (Istituto Nazionale di Statistica, 2025a). The SSN combines public and SSN-accredited private healthcare structures/facilities. Public and private structures have steadily decreased between 2014 and 2021 (Istituto Nazionale di Statistica, 2025a). The northwestern and southern regions have the most healthcare facilities, and the Islands and northeastern areas have the least. The table below shows the division between Public and Private facilities in Italy’s macro-regions in 2021: Northwest 130 139 269 South 131 137 268 Central 103 101 204 Islands 90 71 161 Northeast 68 81 149 Table 1: Public and Private Healthcare Facilities/Structures of the SSN. Similarly, the steadily decreasing number of healthcare facilities has been accompanied by a decline in hospital beds over the same period. However, in 2021, there was a significant increase in the number of hospital beds across the country in response to the urgent need for hospital capacity brought on by the COVID-19 pandemic, which had struck the country particularly hard. In 2014, there were only 3.25 hospital beds per 1000 inhabitants, steadily decreasing to 3.1 per 1000. The increase in 2021 saw the number of beds rise to 3.54 per 1,000 inhabitants (Istituto Nazionale di Statistica, 2025a). The map below shows the regional distribution of inpatient hospital beds in 2021: Regional distribution of inpatient hospital beds across Italy, 2021 Regional distribution of hospitals across Italy, 2021 Figures 1 and 2 illustrate a positive correlation between the number of structures per macro area and the concentration of beds per region. This correlation also contributes to the relative attractiveness of regions for healthcare facilities and services (Agenzia Nazionale per i Servizi Sanitari Regionali, 2024). When looking at the financial flows associated with the movement of patients across regions, some essential key performance indicators (KPIs) provide insight into the attractiveness of regional public and private healthcare facilities and services. The mobility of financial flows provided by the Italian National Agency for Regional Health Services (Agenzia Nazionale per i Servizi Sanitari Regionali, AGENAS) is divided between Passive Mobility (Mobilità Passiva) and Active Mobility (Mobilità Attiva). Passive mobility refers to residents of a particular region travelling to other regions to receive health services; in other words, the outflow of residents to other regions from the region being measured. Relatively high levels of passive mobility can suggest that those regions might have gaps or weaknesses in the healthcare services or facilities they provide. Alternatively, active mobility refers to residents from other regions traveling into a specific region; in other words, the inflow of external patients relative to the region being measured (Agenzia Nazionale per i Servizi Sanitari Regionali, 2024: 4-6). High levels of active mobility can suggest that the region has relatively strong and attractive healthcare facilities and services, which attract patients from other regions. While the scope of what AGENAS provides for health mobility (Agenzia Nazionale per i Servizi Sanitari Regionali, 2024) cannot be covered in this paper, it is important to unpack essential elements to contextualise the findings in line with the scope of this paper. When looking at residents’ active mobility between regions, several KPIs are taken into account to determine the overall attractiveness of a region’s healthcare facilities and services. They include (1) the total attractiveness index (Indice di Attrattività Totale); demonstrating how a region attracts patients from others. A higher value indicates the region has a bigger draw for out-of-region healthcare seekers. (2) Public and private attraction values (Valore Attratto Pubblico Percentuale and Valore Attratto Privato Percentuale); whether a region’s attractiveness is driven more by its public or private healthcare offerings for incoming patients. (3) Financial Gains (Ricavi); the financial revenue earned by the region through its healthcare facilities and services to out-of-region healthcare seekers (Agenzia Nazionale per i Servizi Sanitari Regionali, 2025). Taking these KPIs into collective consideration, in 2023, the Lombardy region stands out with a high attractiveness index of 14.87%, the highest revenues generated by out-of-region patients of all the regions, at a little over € 573 million. When looking at the attractiveness of public and private healthcare offerings, the attracted private value was 73,90% compared to the 26,10% public value. This suggests that the Lombardy region is a hub for healthcare services that attract out-of-region patients, and the SSN-accredited private healthcare offerings drive a large part of that attraction (Agenzia Nazionale per i Servizi Sanitari Regionali, 2025). It is important to note that these flows may occur for several reasons, including patient transfers from regional healthcare facilities to other facilities. Alternatively, the Basilicata region illustrates a different picture in the same year for active mobility. Although Basilicata had a higher attractiveness index of 19.32%, the revenues generated by out-of-region patients were only a little over €22,6 million. Most attractiveness was for public facilities and services at 99,93% compared to 0,17% for private value (Agenzia Nazionale per i Servizi Sanitari Regionali, 2025). The above examples only provide brief insight into the complexity of the regional healthcare system and how its structures and facilities can impact patient flows and revenues. Looking at active and passive patient flows can highlight how regions differ in attractiveness due to specialised private healthcare or better-perceived public healthcare services and facilities. It can also indicate areas where service development and perceptions can be improved. A corresponding indicator to the number of hospital beds is the hospitalisation rate. The average hospitalisation rate in Italy in 2022 was 122.5 per 1000 inhabitants. This rate varies across the different regions, with the Aosta Valley region having around 152 hospitalisations per 1000 inhabitants compared to Apulia, of around 106.3 per 1000 inhabitants (Istituto Nazionale di Statistica, 2025a). When evaluating the capacity and efficiency of a healthcare system, one meaningful relationship to consider is the hospitalisation rate and hospital bed availability. The balance between the two is essential, as having a higher hospitalisation rate relative to the number of available hospital beds could lead to overcrowded hospitals, longer waiting times, delayed treatments, and possibly an increase in patient mortality. This further strains resources, which pressures triage decisions, leading to higher costs and burnout of medical staff. The COVID-19 pandemic, although an exceptional occurrence, demonstrated what this strain could look like on the healthcare system. Alternatively, when the number of available hospital beds exceeds the hospitalisation rate, resources are underutilised, resulting in fiscal inefficiencies and ultimately, higher healthcare costs. This could lead to unnecessary hospitalisations to justify the bed occupancy numbers, overburdening medical resources without actual demand (OECD, 2023: 112). Enhancing the SSN Over the past several years, Italy has incorporated Care Networks, Hub-Spoke (H-S) Networks, and the CCM into the SSN as strategic adaptations to the Beveridge model. These innovations aim to overcome challenges posed by demographic shifts and uneven healthcare distribution, particularly in regions with high disease mortality (Ielo et al., 2024). Care Networks focus on territorial healthcare services, emphasising proximity and integration across care levels to offer patients continuous, accessible, and comprehensive care within their local communities. H-S Networks are used for specialised services, organised around central ”Hub” hospitals providing high-complexity care, supported by smaller ”Spoke” facilities handling lower-complexity cases. Italy also integrates digital health solutions under the CCM, enhancing service efficiency and access. This approach uses telemedicine, digital information-sharing, and institutional collaboration to strengthen service coordination and patient-centred care, further reinforcing the SSN’s capacity to deliver equitable and effective healthcare nationwide. Both adaptations aim to improve healthcare efficiency and access to services and information (Corso et al., 2020: 17-18). Networks for Delivering Care within the SSN The network models that the SSN has employed cover primary and secondary care levels. Care networks are designed to provide accessible, continuous, and comprehensive assistance to the local communities. These networks are organised around primary care providers (PCPs), such as family doctors and GPs, who serve as patients’ first point of contact. They work alongside specialists who provide consultations and treatments for more complex health needs. A key feature of these networks is coordination between PCPs and specialists to ensure seamless patient management. Care Networks aim to provide complete levels of care through specialised clinics or home healthcare services rather than sending patients to larger hospitals if appropriate (Ansaldi et al., 2024). Hospitals in the SSN offer inpatient services, emergency care, and advanced procedures, whereas community services include home care, rehabilitation, mental health services, and social support. Digital integration mechanisms, such as telemedicine, enhance accessibility and continuity of care, especially in rural or underserved areas. The Care Networks’ objectives include improving healthcare accessibility, managing chronic conditions through continuous monitoring, and reducing hospital admissions by strengthening outpatient and community care. These goals aim to create a more patient-centred, efficient healthcare system (Mauro et al., 2023; Ansaldi et al., 2024). At a regional level, the SSN operates through hierarchical Hub-Spoke (H-S) Networks. These networks aim to optimise healthcare access and specialised care delivery within regions. Hubs, often university-affiliated hospitals, provide advanced care, while Spokes—smaller clinics or GP offices—offer routine services. The goal is for Spokes to function as primary care facilities, referring patients to Hubs only when specialised treatment is needed (Sottoriva et al., 2024: 401-403). A notable example of an H-S network is the Neurorehabilitation Sicilian Network, which comprises three Hubs in Palermo, Catania, and Messina with 16 associated Spokes. This network reduced inter-regional patient transfers by about 40%, illustrating how Spokes help manage patient flow, easing pressure on Hubs and ensuring that specialised care is accessible to those who need it (Ielo et al., 2024). Similarly, the Apulia pre-hospital triage with tele-cardiology network demonstrated a shorter ”door-to-balloon” time for patients with ST-segment elevation myocardial infarction (STEMI) of 90 minutes or less. Using a combination of telemedicine and the H-S network to assess heart attack patients before they get to the hospital resulted in faster treatment and reduced the burden on both Hub and Spoke facilities (Brunetti et al., 201 : 5-8). These outcomes demonstrate the effectiveness of the H-S model in improving care delivery in specific medical fields. Despite these successes, similar to the Care Networks, financial constraints and regional disparities in resource and infrastructure capacity present significant challenges. These disparities are between northern and southern Italy. For instance, 89% of the northern regions have advanced imaging equipment in their Hubs, compared to just 58% in the southern regions. Furthermore, 32% of Spokes lack dedicated professionals or specialists, relying instead on GPs for primary care, which can strain resources and lead to increased referrals to Hubs (Ielo et al., 2024). Technological gaps also persist, particularly in the interoperability of Electronic Health Records between regions, and fragmented medical device protocols require manual data entry at 63% of spokes, which affects care coordination (De Cola et al., 2023; Page et al., 2024). The table below highlights the key differences between the two operational networks: Purpose Localised, integrated care for all patients Specialised care for complex conditions Structure Decentralised across communities Centralised with Hubs supported by Spokes Focus Chronic disease management and primary care Advanced diagnostics and specialised treatments Accessibility Proximity-based Referral-based Typical Coverage Within the province or metropolitan area Within the Region Table 2: SSN healthcare network breakdown These networks have improved healthcare access and reduced geographic disparities. However, regional disparities remain and some patients still require inter-regional transfers for treatment or face other difficulties in reaching the necessary care facilities as observed with the patient mobility (Ielo et al., 2024). To address these disparities, Italy is investing in the Connected Care model, which aims to integrate digital solutions, such as telemedicine and electronic health information sharing, to improve the efficiency and equity of care delivery across regions. The Connected Care model seeks to bridge gaps by enhancing service coordination and making healthcare more accessible with a focus on patient-centred healthcare (Corso et al., 2020). By leveraging digital technologies, the Connected Care model aims to reduce unnecessary patient transfers, streamline healthcare delivery, and further support the SSN’s goals of equitable healthcare provision. Continued investment in both infrastructure and digital health solutions is crucial to mitigating these disparities and ensuring the long-term success of Italy’s healthcare system. The following section contextualises Italian eHealth to unpack and understand the Connected Care model. The SSN and eHealth As part of Italy’s healthcare modernisation efforts, it is developing a comprehensive Health Data Ecosystem known as the “ecosistema dei dati sanitari”. The ecosystem aligns with Italian health goals and aspirations and the EU’s Health Data Space (Ministero della Salute, 2025b). The Italian Health Data Ecosystem incorporates a broad and diverse range of data generated and later used by patients, healthcare providers, regional health authorities and research institutions. The electronic health record is an essential element of this ecosystem (Fascicolo Sanitario Elettronico 2.0, FSE 2.0). The FSE 2.0 is the second variation of Italy’s digital health record and was designed to be the central platform that facilitates the secure and interoperable exchange of patient health information (Ministero della Salute, 2025c). The National Agency for Digital Health (Agenzia Nazionale per la Sanità Digitale, ANSD) builds, monitors, and ensures that data governance and interoperability standards are maintained for this ecosystem. The ANSD is supported by the Ministry of Health and several regulations and guidelines, which have established the technical and operational parameters for implementing FSE 2.0 at the national level. At an international level, the ANSD is the referral point and governance body within the Health Data Ecosystem to access and manage Italian health data within the EU Health Data Space (European Parliament and Council, 2025). The creation and development of the Italian Health Data Ecosystem align with national and broader European strategies to leverage digital systems and technologies to improve healthcare delivery, medical research, and overall public health. The overarching goal is to encourage the adoption of the Connected Care model, in which a seamless and secure flow of health data will empower and engage patients and assist healthcare providers’ work. This, in turn, should enhance the efficiency and effectiveness of the SSN (Ministero della Salute, 2025b). The SSN and eHealth: Connected Care In 2019, Italy formalised the Connected Care Model (CCM) under the ”Piano Nazionale per la Connected Care” as part of the Health Data Ecosystem to address the challenges of an ageing population and the growing prevalence of chronic diseases. The CCM is a digital health initiative integrating healthcare facilities to offer continuous care through digital communication channels (Corso et al., 2020). This initiative aligns with the European Union’s broader goals for digital health and represents Italy’s move towards a digital healthcare ecosystem (European Parliament and Council, 2025). The model incorporates advancements in telemedicine and the interoperability of electronic health records (FSE 2.0), allowing patients to access lab results, imaging studies, and treatment plans via regional portals (Corso et al., 2020; Ministero della Salute, 2025c). An example of the Connected Care model being operationalised is the IRCCS Policlinico San Donato telemedicine pilot. The San Donato Group’s telemedicine service was updated to enhance and expand its functionality. The pilot allows users to book telemedicine visits, receive virtual consultations and online written consultations with hospital specialists directly from the online services section. The original telemedicine platform was launched in 2020. The pilot platform was launched in October 2023 and aligned with the Connected Care model, with the intention of integrating into the digital healthcare ecosystem and gradually involving all doctors and administrative staff of the Group’s facilities. Currently, the project is active in 15 facilities of the San Donato Group, involving hundreds of doctors and thousands of patients (Gruppo San Donato, 2024). Some challenges remain in fully realising the potential of the Connected Care model. A significant barrier is the digital divide. The digital divide refers to the gap in access to and literacy in digital technologies, particularly among older populations. In the Italian context, only about 45,8% of individuals between the ages of 16 and 74 have basic or above basic digital skills. Furthermore, 41% of Italians over 75 lack internet access. Generally, low digital literacy skills can severely limit telemedicine adoption (Eurostat, 2024). Additionally, regional discrepancies in technological infrastructure exacerbate these challenges. While 89% of northern Italian clinics are compatible with electronic health records, only 58% of southern clinics are, highlighting a clear north-south divide in digital health capabilities (Bobini et al., 2023 ; Page et al., 2024). Another significant barrier is the gap in workforce training and the adoption of eHealth and telemedicine technologies. Many healthcare professionals lack adequate training to utilise digital health tools, which impedes the model’s success despite interest in using the technology (Locatelli et al., 2023: 32-35). Furthermore, the decentralised nature of the SSN leads to coordination and standardisation issues across regions, affecting the effectiveness of the CCM and demonstrating inconsistencies in adopting critical technologies across all healthcare structures (The Lancet Regional Health – Europe, 2025). The interaction between the Care Networks, H-S Networks and the CCM is crucial for improving healthcare delivery. The decentralised structure of the SSN complicates coordination and leads to fragmented care pathways. This fragmentation places additional burdens on both healthcare providers and patients (The Lancet Regional Health – Europe, 2025). Sometimes, Hubs and Spokes fail to adhere to standardised care protocols, which could affect patient outcomes, increase costs, and cause difficulty in follow-up procedures. It has been demonstrated in the Molise-Naples H-S collaboration that non-urgent surgeries requiring specialist physicians can take place across regions and have positive effects. A lack of integration between Hubs and Spokes in certain regions causes delays in follow-up care and impacts the speed of treatment and follow-up checks (Buondonno et al., 2022). Despite these challenges, the CCM has shown promise in improving healthcare access and reducing inefficiencies. The model’s continued success depends on overcoming the barriers created by the Digital Divide, regional disparities, and insufficient workforce training. Additionally, greater standardisation of care pathways and better integration between Hubs and Spokes are essential for ensuring consistent and equitable care across the SSN. The Italian eHealth system has made significant strides in providing the necessary tools for Digital Health Communication and Bioinformatics, offering patients and healthcare professionals access to health information (Page et al., 2024). Despite good progress, in 2023, Italy’s healthcare providers were still limited in terms of connectivity and data sharing within the broader eHealth network, resulting in data silos at regional and categorical levels (Page et al., 2024). These silos hinder the flow of complete information from health ICT systems to Electronic Health Records (EHRs), undermining the effectiveness of digital health tools. While Italy’s digital health maturity advances, implementing digital systems remains inefficient across all regions and sectors (Page et al., 2024; Agenzia Nazionale per i Servizi Sanitari Regionali, 2024). This issue became particularly evident during and after the COVID-19 pandemic, as the adoption of digital health technologies was inconsistent across the country. To fully realise the model’s potential, a coordinated and integrated effort is needed to address existing technological, infrastructural, and training gaps. Continued investment in digital health infrastructure, workforce development, and efforts to reduce regional disparities will enhance healthcare delivery and achieve more equitable outcomes for all citizens. Digitalisation Efforts Since 2011, there have been progressive efforts to address these gaps. During the COVID-19 pandemic, just under 32% of Italian clinicians felt that their organisations were very well prepared to adopt digital technologies. Approximately 42% thought they were reasonably prepared , and just under 23% felt they were only slightly prepared (Deloitte, 2020: 18). This sentiment came despite a gradual increase in expenditure on digital healthcare from € 1.3 billion in 2011 to € 1.5 billion in 2020. The most significant rise in funding occurred between 2020 and 2021, when spending increased from € 1.5 billion to € 1.69 billion. Although there was a consistent rise in digital healthcare investment, clinicians still believed that several challenges must be addressed to implement digital healthcare technologies successfully. These included bureaucratic barriers, inadequate staff training, and the high costs of the technologies themselves (Deloitte, 2020: 18; OECD/European Commission, 2024: 141-151). As a result, Italy’s adoption rate of digital health technologies has remained relatively low. Only half of clinicians reported adopting online access platforms and tools for primary hospital care, and mobile app usage was similarly underutilised. Additionally, only 38% of clinicians used telemedicine, despite the potential of this technology to transform patient care. However, around 69% of clinicians reported using electronic health records. The telemedicine services clinicians’ primary uses are for tele-consultations with specialist physicians, tele-reporting, and tele-visits. Few clinicians employed telemedicine for teleconsultations with general practitioners (GPs), teleassistance, or telerehabilitation services (Locatelli et al., 2023: 27-31). In 2023, the Italian government allocated a portion of the National Recovery and Resilience Plan (PNRR) funding to enhance and develop the country’s telemedicine services. This initiative aimed to improve healthcare accessibility, prioritising primary care and boosting telemedicine services throughout the country. Despite currently low usage, interest in telemedicine services has been growing, with just over a quarter of Italians with chronic diseases already using telemedicine services provided by pharmacies. While adoption remains low, more than half of Italians have expressed interest in using telemedicine services, though less than a quarter have utilised them (Locatelli et al., 2023: 26-27). Italy’s EHR usage has also been critical to its digital healthcare journey. During the fourth quarter of 2023, around 70% of Italians were using EHRs, below the EU average of 81%. At the physician level, only 12 out of Italy’s 21 regions had 70% or more qualified physicians using the EHR system, with only five regions reporting 100% usage by qualified physicians. At the patient level, in the 11 regions where patients were using the EHR, only three had more than 30% of patients actively using their EHRs in the last quarter of 2023 (Page et al., 2024; Statista, 2024: 5). Satisfaction and Use Regarding patient satisfaction, Italians have generally been happy with the healthcare facilities and care received over the past two decades. The Italian National Institute for Statistics (Istituto Nazionale di Statistica, ISTAT) conducted patient satisfaction interviews of patients who had made at least one hospital visit from 2006 up to 2023: an average of 87.97% of respondents were happy with the nursing services in these structures, and 80.26% were satisfied with the sanitary facilities available. 90.08% were satisfied with the medical care received in Italian hospitals. Public perceptions and accessibility of healthcare systems appear to hold differing sentiments. Statements were posed to a panel (Istituto Nazionale di Statistica, 2025b), and the participants were asked whether they agreed or disagreed with four key statements concerning the delivery of public healthcare and accessing public health services and information. Regarding healthcare delivery, 76% of participants believed that waiting times to schedule an appointment with a doctor were too long, and 74% thought the Italian healthcare system was overstretched (Istituto Nazionale di Statistica, 2025b). Regarding accessing public healthcare information and services, only 34% of participants felt that information about healthcare services is readily available, and 37% thought that information on how to look after their health is readily available when needed. Only 28% of participants felt it was easy to schedule an appointment with a doctor in their local area (Ipsos, 2024: 41-47). Despite the high level of care satisfaction, the public struggles to access the public health system effectively, particularly in the new eHealth systems and technologies being implemented to improve healthcare accessibility and delivery. Conclusion Italy has taken strides towards improving its eHealth maturity in recent years, more so during and shortly after the COVID-19 pandemic, increasing investments in physical and digital infrastructure and technologies to address the shortage of healthcare professionals and an ageing population. Even so, these new systems and technologies are unevenly implemented across regions, outside of the nationally mandated essential levels of care. Furthermore, healthcare professionals face a digital skills level development challenge, and digital exclusion amongst an ageing population who would benefit the most from these digital systems and technologies. Sustained progress in eHealth significantly hinges on healthcare professionals’ and patients’ awareness and competence regarding these technologies. While the development of telemedicine services, improvements, and continued rollout of the FSE offer a promising prospect for Italian eHealth, further integration into the broader healthcare network across all regions is still required. Accessibility and usability barriers to digitalisation efforts will persist amongst the aforementioned groups if stakeholders at regional and national levels do not collectively address digital literacy, capability, and awareness of eHealth systems and technologies. To the extent that digital literacy is a fundamental aspect of modern literacy, integral to education, employment, and civic engagement in the contemporary world, digital illiteracy is a social issue, requiring the attention, input and intervention of the broader society which includes educators at various levels, social workers, local community and family members. Whilst the national and regional health authorities have a key role in developing and promoting digital healthcare, digital literacy advocacy is a responsibility of the broader society in the same way as literacy is. Bibliography: Agenzia Nazionale per i Servizi Sanitari Regionali. 2022. “Reti cliniche ospedaliere”. [Online]. Available at: https://www.agenas.gov.it/aree-tematiche/organizzazione-dei-servizi-sanitari (Accessed: 13 February 2025). Agenzia Nazionale per i Servizi Sanitari Regionali. 2024. “La Mobilità Sanitaria in Italia - Edizione 2023”. [Online]. Available at: https://www.agenas.gov.it/i-quaderni-di-monitor-\%E2\%80\%93-supplementi-alla-rivista/2479-la-mobilit\%C3\%A0-sanitaria-in-italia-edizione-2023 (Accessed: 13 February 2025). Agenzia Nazionale per i Servizi Sanitari Regionali. 2025. “Mobilità Sanitaria”. [Online]. Available at: https://stat.agenas.it/web/index.php?r=public\%2Findex\&report=10 (Accessed: 13 February 2025). Ansaldi, F., Astengo, M., Battaglini, A., Grammatico, F., Marchini, F., Fiorano, A., Allegretti, S., Schenone, I., Amicizia, D. 2024. “A new organizational model of primary healthcare in Liguria, Italy. Insights and implications”. Journal of Preventive Medicine and Hygiene . 65(2):236-244. Bobini, M., Boscolo, P, R., Caccia, C., Petracca F., Rotolo, A. 2023. “La telemedicina verso il consolidamento: assetti organizzativi formalizzati ed emergenti nel SSN”. In Rapporto OASI 2023 : 473-512. Brunetti, N, D., Di Pietro, G., Aquilino, A., Bruno, A, I., Dellegrottaglie, G., Di Giuseppe, G., Lopriore, C., De Gennaro, L., Lanzone, S., Caldarola, P., Antonelli, G. 2014. “Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: data from the Bari-Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction”. European Heart Journal: Acute Cardiovascular Care , 3 (3): 204-213. Buondonno, A., Avella, P., Cappuccio, M., Scacchi, A., Vaschetti, R., Di Marzo, G., Maida, P., Luciani, C., Amato, B., Brunese, M, C., Esposito, D. 2022. “A hub and spoke learning program in bariatric surgery in a small region of Italy”. Frontiers in Surgery , 9 . Corso, M., Lettieri, E.,Locatelli, P.,Masella, C., Sgarbossa, C., De Cesare, D. 2020. “Connected Care ed Emergenza Sanitaria: Coasa Abbiamo Importato e Cosa Fare Adesso?”. Politecnico Milano School of Management: Osservatorio Innovazione Digitale in Sanità. De Belvis AG, Meregaglia M, Morsella A, Adduci A, Perilli A, Cascini F, Solipaca A, Fattore G, Ricciardi W, D’Agostino M, Maresso A, Scarpetti G. 2024b. “Italy: Health System Summary”. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2024. Licence: CC BY-NC-SA 3.0 IGO. De Belvis, A,G., Meregaglia, M., Morsella, A., Adduci, A., Perilli, A., Cascini, F., Solipaca, A., Fattore, G., Ricciardi, W., D’Agostino, M., Maresso, A., Scarpetti, G. 2024. “Italy: Health System Summary, 2024”. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2024. Licence: CC BY-NC-SA 3.0 IGO. De Belvis, A,G., Meregaglia, M., Morsella, A., Adduci, A., Perilli, A., Cascini, F., Solipaca, A., Fattore, G., Ricciardi, W., Maresso, A., Scarpetti, G. 2022. “Italy: Health system review”. Health Systems in Transition . 24(4). De Cola, M, C., Ielo, A., Lo Buono, V., Quartarone, A. and Calabrò, R, S. 2023. “Toward social-health integration in Sicily: description of the first hub and spoke model to improve the diagnostic therapeutic care paths for neurorehabilitation”. Frontiers in Public Health , 11. Deloitte. 2020. “Digital transformation: Shaping the future of European healthcare”. Deloitte Centre for Health Solutions. [Online]. Available at: https://www.deloitte.com/dk/en/Industries/government-public/research/shaping-the-future-of-european-healthcare.html (Accessed: 10 March 2025). European Parliament and Council. 2025. “Regulation (EU) 2025/327 of the European Parliament and of the Council of 11 February 2025 on the European Health Data Space and amending Directive 2011/24/EU and Regulation (EU) 2024/2847 (Text with EEA relevance)”. [Online]. Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/HTML/?uri=CELEX:32025R0327 (Accessed: 14 March 2025). Eurostat. 2024. “Statistics Explained: Skills for the digital age”. [Online]. Available at: https://ec.europa.eu/eurostat/statistics-explained/index.php?oldid=644626\&utm (Accessed: 13 February 2025). Garattini, L., Badinella Martini, M. & Zanetti, M. 2022. “The Italian NHS at regional level: same in theory, different in practice”. European Journal of Health Economics. 23: 1–5. Greco, G., Giulio de Belvis, A., Meregaglia, M., Fattore, G., Ricciardi, W. 2024a. “Health Systems in Transition (HiT) profile. Country Overview: Italy”. Physical and human resources . [Online]. Available at: https://eurohealthobservatory.who.int/monitors/health-systems-monitor/countries-hspm/hspm/italy-2023/physical-and-human-resources/human-resources\#planning-and-registration-of-human-resources (Accessed: 14 March 2025). Gruppo San Donato. 2024. “La nuova Telemedicina di Gruppo San Donato” [Online]. Available at: https://www.grupposandonato.it/servizi-telemedicina-teleconsulto (Accessed: 13 February 2025). Ielo, A. Quartarone, A., Calabrò, R.S., De Cola, M.C. .2024. “A hub and spoke model to supply the Sicilian neurorehabilitation demand: Effects on hospitalization rates and patient mobility”, Frontiers in Public Health , 12: 1-9. Ispos. 2024. “Ipsos Health Service Report 2024”. [Online]. Available at: https://www.ipsos.com/sites/default/files/ct/news/documents/2024-09/Ipsos-Health-Service-Report-2024-Global-Charts.pdf (Accessed: 14 March 2025). Istituto Nazionale di Statistica. 2025a. “Servizi sanitari e loro ricorso”. [Online]. Available at: https://esploradati.istat.it/databrowser/\#/it/dw/categories/IT1,Z0810HEA,1.0/HEA_SERVICES/HEA_SERVICES_HOSP (Accessed: 11 March 2025). Istituto Nazionale di Statistica. 2025b. “Soddisfazione per i vari aspetti del ricovero”. [Online]. Available at: http://dati.istat.it/Index.aspx?lang=it\&SubSessionId=621881bc-d39a-4ead-baeb-1d4cd095b4f8 (Accessed: 14 March 2025). Lee, T. and Porter, M., 2013. The strategy that will fix healthcare . Harvard Business Review. Locatelli, P.,Masella, C., Sgarbossa, C., De Cesare, D., Olive, M. 2023. “Telemedicina: il modello di matura dei servizi e la diffusione in Italia”. Politecnico Milano School of Management: Osservatorio Innovazione Digitale in Sanità. Longo, F., Locatelli, F., Del Vecchio, M., Di Giulio, P., Giordano, S., Odone, A., Ranieri, V., Vineis, P . 2024. ‘Tackling the crisis of the Italian National Health Fund’, The Lancet Public Health , 9(1): e6-e7. Mauro, M. and Giancotti, M. 2023. “The 2022 primary care reform in Italy: Improving continuity and reducing regional disparities?”. Health Policy , 135. Ministero della Salute. 2023. “Livelli Essenziali di Assistenza, sintesi dei risultati del nuovo sistema di garanzia 2023, Ministero della Salute - Livelli essenziali di assistenza, sintesi dei risultati del Nuovo Sistema di Garanzia 2023”. [Online]. Available at: https://www.salute.gov.it/new/it/news-e-media/notizie/livelli-essenziali-di-assistenza-sintesi-dei-risultati-del-nuovo-sistema-di/?tema=Livelli\%2Bessenziali\%2Bdi\%2Bassistenza (Accessed: 11 March 2025). Ministero della Salute. 2024a. “Piano Nazionale di Ripresa e Resilienza. Cos’è la missione salute”. [Online]. Available at: https://www.pnrr.salute.gov.it/portale/pnrrsalute/dettaglioContenutiPNRRSalute.jsp?lingua=italiano\&id=5833\&area=PNRR-Salute\&menu=missionesalute (Accessed: 11 March 2025). Ministero della Salute. 2024b. “Bilancio di previsione dello Stato per l’anno finanziario 2025 e bilancio pluriennale per il triennio 2025-2027. (24G00229)”. [Online]. Available at: https://www.trovanorme.salute.gov.it/norme/dettaglioAtto?id=104538 (Accessed: 11 March 2025). Ministero della Salute. 2025a. “Livelli essenziali di assistenza, sintesi dei risultati del Nuovo Sistema di Garanzia 2023”. [Online]. Available at: https://www.salute.gov.it/new/it/news-e-media/notizie/livelli-essenziali-di-assistenza-sintesi-dei-risultati-del-nuovo-sistema-di/?tema=Livelli+essenziali+di+assistenza (Accessed: 11 March 2025). Ministero della Salute. 2025b. “Ecosistema dei dati sanitari” [Online]. Available at: https://www.salute.gov.it/new/it/tema/fascicolo-sanitario-elettronico/ecosistema-dei-dati-sanitari/ (Accessed: 11 March 2025). Ministero della Salute. 2025c. “Fascicolo Sanitario Elettronico 2.0”. [Online]. Available at: https://www.salute.gov.it/new/it/tema/fascicolo-sanitario-elettronico/il-fascicolo-sanitario-elettronico-20/ (Accessed: 11 March 2025). OECD. 2023. “Health at a Glance 2023: OECD Indicators”. OECD Publishing, Paris. [Online]. Available at: https://doi.org/10.1787/7a7afb35-en . OECD/European Commission. 2024. “Health at a Glance: Europe 2024: State of Health in the EU Cycle”. OECD Publishing, Paris. [Online]. Available at: https://doi.org/10.1787/b3704e14-en . Page, M., Winkel, R., Behrooz, A., Bussink, R. 2024 .“ 2024 DIGITAL DECADE EHEALTH INDICATOR STUDY – ANNEX: Italy”. Publications Office of the European Union. Sottoriva, C, B., Del Vecchio, M., Giacomelli, G., Montanelli, R., Sartirana, M., Vidè, F. 2024. “Configurazione delle reti ospedaliere e organizzazione del personale: quali strategie e leve aziendali?”. Rapporto OASI 2024. Università Bocconi: 395-420. Statista. 2024. “Digital healthcare in Italy”. Statista Research Department. The Lancet Regional Health – Europe. 2025. “The Italian health data system is broken”. The Lancet Regional Health-Europe , 48 . Information & Authors Information Version history V1 Version 1 15 April 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords digital health healthcare healthcare system italian healthcare pnrr ssn Authors Affiliations Alessandro Giovanni Vincenzo Napoli 0009-0007-0699-2476 [email protected] View all articles by this author Metrics & Citations Metrics Article Usage 1919 views 283 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Alessandro Giovanni Vincenzo Napoli. Italy’s National Healthcare System and eHealth Landscape: A Multilayered System of Health and Digital Health Services. Authorea . 15 April 2025. DOI: https://doi.org/10.22541/au.174475411.13465851/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); Cited by Mohammed Alkhaldi, Rima Kachach, Aisha Al Basuoni, Line Enjalbert, Malak Alrubaie, Maya Hassan, Sara Ahmed, National HTA system in Canada: From system analysis and understanding to system strengthening, PLOS Global Public Health, 6 , 4, (e0005858), (2026). https://doi.org/10.1371/journal.pgph.0005858 Crossref Loading... View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.174475411.13465851/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fec5f06cfd78e2e',t:'MTc3OTI5MDkwNg=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();