Digitalization of an Integrated “Social and Health” Care Path

Barbara Leoni

, Erika Guareschi

and Marco Foracchia

Head of Territorial Clinical Informatics Unit,

Azienda USL Reggio Emilia IRCSS (Reggio Emilia Local Health Authority), Italy

Head of Electronic Medical Records Unit,

Azienda USL Reggio Emilia IRCSS (Reggio Emilia Local Health Authority), Italy

Chief Information Officer, Azienda USL Reggio Emilia IRCSS (Reggio Emilia Local Health Authority), Italy

Keywords: Electronic Health Record, Integrated Care Pathway, Social and Healthcare Services, Non-Self-Sufficient,

Disabilities, Configurable Platform, Single Points of Access, Elderly.

Abstract: The integrated care pathway, designed by the Italian regulatory framework, for individuals who are non-

self-sufficient or have serious disabilities, is crucial not only to address healthcare needs but also to meet

social needs. It provides access to social and healthcare services through single points of access (PUA) and

multidisciplinary integrated teams working at PUAs to define the integrated individual care plan (PAI).This

pathway must be organized through close collaboration between healthcare organizations and local social

services, requiring integration of services, human resources, as well as the digitalization of processes and

interoperability between IT systems. The introduction of a shared computerized platform, configurable and

interoperable, enables the creation of a unified socio-health record, facilitating a truly integrated and

digitalized care journey where the patient is at the center of attention.

1 INTRODUCTION

The use of a platform for a unified electronic health

record across hospital, local, and social healthcare

pathways (even beyond the healthcare organization)

enables the sharing of information, process

integration and monitoring of effectiveness and

efficiency throughout most of the life-long care paths

of the citizens of the Reggio Emilia province.

The approach adopted in the Reggio Emilia Local

Health Authority, in line with regional and national

strategy and regulations, extends the well-established

experience developed in the hospital network beyond

the traditional adoption of Electronic Medical Record

systems. The resulting digital ecosystem ensures a

comprehensive, patient-centered perspective that

follows care paths beyond the acute-care hospital

encounters extending towards population and

chronicity management and even the management of

collateral, yet critical social needs of our citizens.

The adoption of a single comprehensive solution

also allows for better management of privacy issues

(regulated by the European GDPR) by means of a

structural dynamic segmentation of the personal

datasets.

2 CONTEXT

Social and health assistance aims to contribute to the

creation of an integrated system of social, socio-

health, and health services, which together form the

welfare of the community at local, regional, and

national levels. In Italy, healthcare management is

entrusted to healthcare organizations, while the social

component falls under the responsibility of municipal

Social Services.

Effective integration and collaboration between

various stakeholders are essential for the proper

functioning of the system. This process is facilitated

by the establishment of Single Access Points (PUAs),

which enable individuals in conditions of non-self-

sufficiency to access social and health services

through a single entry point. Multidisciplinary teams,

composed of adequately trained professionals,

operate within PUAs to address the health needs of

individuals comprehensively. These teams employ

organizational models that integrate social services,

guiding and attending to citizens' needs.

The functions of Single Access Points include

reception, information, orientation, assessment,

support, and monitoring. They serve as the primary

point of reference for assessing and providing care to

338

Leoni, B., Guareschi, E. and Foracchia, M.

Digitalization of an Integrated “Social and Health” Care Path.

DOI: 10.5220/0013431600003938

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 11th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2025), pages 338-342

ISBN: 978-989-758-743-6; ISSN: 2184-4984

people with complex needs who require coordinated

health and social interventions.

2.1 Demographic Context

In the socio-demographic context of Reggio Emilia,

there is a significant elderly population (see Table 1),

alongside vulnerable groups such as those with

disabilities and those experiencing social

marginalization. This demographic landscape

underscores the growing need for an integrated

approach to address these issues, with particular

attention to future challenges.

Figure 1: Demographic situation of the province of Reggio

Emilia (2024)

2.2 The Local Health Authority

The Local Health Authority of Reggio Emilia is one

of the first Italian entities born from the merger of a

Territorial Health organization and a large Hospital,

in 2017. Consistently at the forefront of digital

healthcare, it has attained Level 6 HIMSS

accreditation, one of the highest international

standards, shared by only six other Healthcare

Autorithies in Italy and fourteen across Europe.

The current Authority covers five peripheral

hospital facilities and the Arcispedale Santa Maria

Nuova Hospital of Reggio Emilia, all integrated into

a complex territorial network that includes Hospices,

Health Houses, Women's Health Centers, Outpatient

Clinics, Mental Health Centers, and other services. It

serves a population of about 530,000 inhabitants,

21% of whom are over 65 years old, with a birth rate

of 9 births per thousand inhabitants.

The organization consists of about 7,900

employees, 81% of whom work in the healthcare

sector, and 19% in other fields. The merger of the two

organizations allowed for the sharing of innovative

solutions, especially in the hospital field, which were

adapted and applied to territorial processes. This

approach enabled the organization to be one of the

first in Italy to adopt computerized systems for

managing out-of-hospital pathways, such as

Population Screening, Home Care, and Integrated

Pathways, starting in the early 2000s.

3 THE PLATFORM

The Local Health Authority of Reggio Emilia, driven

by the need to evolve in contexts beyond traditional

hospital departments, identified the need to adopt a

platform that was:

• Highly configurable and adaptable to various

pathways and settings

• Built with cutting-edge technologies, ensuring

adequate performance

• Fully integrated with the province, regional and

national Digital Health Ecosystem

• Designed according to the "Privacy by Design"

paradigm

This project was not just about acquiring a system,

but creating and adopting a complete a set of digital

solutions and services to support the organization’s

digitalization.

The experience stemps from the initial goal of a

full digital management of the hospital clinical

pathway: the Matilde platform was born from this

need.

The resilience and adaptability of the system

allowed for replicating established best practices in

the hospital environment, applying them flexibly and

effectively to territorial contexts, which by their

nature are less standardized. The project gradually

extended its scope, aiming at complete management

of the patient’s clinical pathway, including extra-

hospital settings, territorial pathways, and socio-

healthcare pathways.

The platform is based on a cloud-based

environment provided by the Regional public

Healthcare dedicated cloud infrastructure. This

guarantees proper management and scale-up

capabilities typical of cloud solutions, together with a

geographically redundant Disaster-Recovery

architecture. National regulations also allow for

mission-critical organizations like the Reggio Emilia

Hospital Network to keep a “break the glass” local

infrastructure that can back-up the cloud solution in

case of major connection issues. This local

emergency environment guarantees the availability of

currently active care paths and main functionalities

and integrations.

Matilde platform is fully integrated with the

province, regional and national healthcare digital

ecosystem, specifically:

• Master Patient Index, linked to the National

Health MPI (ANA: Anagrafe Nazionale

Assistiti)

• Patient management systems (PMS), which

handle all patient encounters (hospital

admissions, transfers, discharges) and

Digitalization of an Integrated “Social and Health” Care Path

339

territorial care processes (home care, chronic

care pathways, etc.)

• Clinical Data Repository, which gather and

distributes in standardized formats (e.g. HL7

CDA2) the totality of documents and datasets

generated by the over 200 information

systems connected

• PACS/VNA, which manages the province

enterprise imaging framework

• Order Entry ESB, a general middleware

adopted for the reception dispatching and

updating of computerized orders of all types

(e.g. lab requests, transports, meals,

activation of social services)

• Administration Datawarehousing used to

collect all the production data used for billing

and controller functions

Privacy is guaranteed by a sophisticated, yet

centralized and harmonic management of access

permissions to single datasets and records. It is

possible to configure access to specific parts of

information of a person’s record to groups of users

(Roles). Over 200 user Roles have been identified to

mange a capillary distribution of access permissions.

The platform allows for the dynamic modulation

of these permissions based on the care path and

processes affecting the person’s life, thus allowing for

the proper extension of access privileges upon the

change of setting, responsibilities and clinical status

of the person.

The resulting robust, configurable and fully

integrated Matilde platforms, allows to create

records, pathways, and manage all patient data, as

well as access all data coming from integrated

systems.

All activities necessary for the implementation

and configuration of the platform are carried out by

organizational internal team within the organization,

allowing for a fast and vendor-independent

management of both operations and system

activation/scale-up. The industry vendors proving the

solution are only involved in major functional or

architectural upgrades.

The overall strategy of extension and

development of the Matilde platform in managed by

a multidisciplinary team officially appointed by the

Local Health Authority Board that includes doctors,

healthcare and social professionals, pharmacists, risk

management and privacy experts.

The system, in its main modules, is available as an

open source solution, according to Italian regulations

for software systems developed within public

organization (https://developers.italia.it/it/software/

auslre-ausl-reggioemilia-matilde.html )

4 METHODOLOGY AND

IMPLEMENTATION

In 2024, the Unified Access Points (PUA) were

introduced at the Local Health Authority of Reggio

Emilia, leveraging both healthcare and social

operators from the organization itself and the

territorial social services managed by the local

municipalities.

Figure 2: Adoption of the Matilde Platform.

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In parallel with the PUAs, the Territorial

Operational Center (COT) manages patient setting

transfer requests, coming from both hospitals and

territorial services.

A transfer record developed on the Matilde

platform specifically for the Territorial Operational

Centers, already allows for the consolidation of all

requests for the activation of protected discharge

pathways from the hospital network into a single,

computerized channel. This channel, integrated with

the hospital record system, facilitates the assessment

of the appropriateness of each request, as well as the

definition of the patient's needs and the services to be

activated.

PUA operators need to monitor and integrate

healthcare, socio-healthcare, and social services,

involving not only the patient and their family but

also General Practitioners and other healthcare and

social professionals.

To ensure a seamless and integrated intervention,

the decision was made to create a computerized

record for the PUAs, using the Matilde platform. This

solution enables operators to:

• Collect patient Privacy Authorizations

settings, thus limiting the access to the

information to the specific professional roles

involved in the care path

• Record patient and caregiver contact details,

along with information on needs and the

socio-healthcare context

• Access health data, including hospital

admissions, home care, the use of aids or

devices, chronic care pathways, etc.

• Manage and monitor all activationsof Health

and Social Services coming both from the

Hospitals network and the territorial units

• Activate transfer services managed by the

COT

• Request healthcare services, such as the

provision of medical aids, devices, or

activation of care pathways

All the functionalities are within the scope of the

Matilde Platform and its integrated digital ecosystem,

therefore the implementation is limited to configuring

the specific datasets and authorizations to access the

information coming from specific integrated systems

(e.g. access to the healthcare related admissions) or

issuing orders to these systems (e.g. requesting

medical aids, activation of social services, activation

of transport services).

The resulting Matilde record provides a

comprehensive, patient-centered view that enables

the detection of needs and vulnerabilities while

allowing for the effective management and

assessment of the most appropriate pathways to

support the patient’s health and social situation.

5 RESULTS AND FUTURE

DEVELOPMENTS

The adoption of a comprehensive, configurable, and

scalable platform enables a holistic management of

patient pathways and access to territorial and social

services.

This approach enhances:

• better tracking of activities (many of

which were previously recorded on paper)

• reduction of paper consumption

• processes simplification (such as booking

and activating services, and accessing the

patient’s complete health profile)

• reduction of waiting times

• mitigation of risks through a more

structured management of data and

process

The introduction of Matilde for PUA operators

marks just the beginning of a broader effort to involve

all healthcare and social professionals within the

provincial ecosystem.

The integration of the system with the social

network is continuously expanding, now including

external organizations that care for vulnerable

patients, as well as the Territorial Social Services of

the municipalities.

This expansion will lead to the creation of a

unified socio-healthcare network across the province,

which will include:

• Local Health Authority and the 6 Provincial

Hospitals

• Territorial Healthcare Facilities

• 34 Day and Residential Centers for Disabled

Individuals

• 90 Residential Centers for Elderly People

• Social Services from 46 Municipalities of the

Province

An integrated network will foster better

coordination and more efficient care delivery across

the region.

REFERENCES

Law No. 234, 2021 - Article 1 - Unified Access Points

(PUA)

Emilia Romagna Region - Resolution No. 2161 of

12/12/2023, Guidelines for the Design and

Digitalization of an Integrated “Social and Health” Care Path

341

Implementation of Unified Access Points (PUA) and the

Definition of Program Agreements for Socio-

Healthcare Integration for Individuals with

Dependency or Disabilities

Italian National Institute of Statistics (ISTAT) - Resident

population by age, sex and marital status on 1st

January 2024 - https://www.istat.it/en

AGENAS - Territorial Operational Centers (COT) Model,

https://www.agenas.gov.it/pnrr/missione-6-

salute/implementazione-delle-centrali-operative-

territoriali-cot

AGID - Guidelines for Software Reuse in Public

Administration, https://www.agid.gov.it/it/design-

servizi/riuso-open-source/linee-guida-acquisizione-

riuso-software-pa

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