ASP Cosenza — Deliberation No. 359, 2 April 2026 Approval of the PAGLA 2026/2027 (Piano Aziendale di Governo delle Liste di Attesa) pursuant to Law 107/2024 and the Calabria Regional Waiting List Plan (DCA 42/2026).

On 2 April 2026, the Azienda Sanitaria Provinciale (ASP) di Cosenza — the Local Health Authority serving the province of Cosenza in Calabria, Southern Italy — formally adopted its biennial Waiting List Governance Plan (PAGLA 2026/2027) through Deliberation No. 359, signed by the Extraordinary Commissioner, Dr Vitaliano De Salazar.

The 31-page document is a comprehensive operational blueprint covering demand governance, supply-side restructuring, CUP (Central Booking System) centralisation, telemedicine integration, surgical backlog recovery, and a detailed financial plan backed by over €8.6 million in dedicated funding. It is a serious piece of healthcare planning for a province of over 700,000 inhabitants spread across one of Italy’s most geographically challenging territories.

But buried in Section 11.2 of the plan, there is a passage that caught my attention as Italy’s Ambassador for Hospitals on FHIR (HoF) under HL7 Europe — a passage that, to my knowledge, represents a first for an Italian Local Health Authority of this kind.

The passage: HL7 FHIR prescribed by name in a waiting list plan

Section 11.2 of the PAGLA deals with direct access services — specifically, Mental Health Departments, Family Health Clinics (Consultori Familiari), and Addiction Services (SerD). These are services where Italian law allows citizens to seek care without a GP referral, given the sensitive and often urgent nature of their needs.

The plan establishes three binding operational provisions for these services. The first is an absolute prohibition on paper-based scheduling: no more handwritten appointment books, no more personal registers, no more untracked agendas. The second is a mandatory digital registration procedure for every service delivered, eliminating what the document calls “managerial invisibility” from national data flows.

The third provision is the one that matters most for the interoperability community:

From PAGLA Section 11.2, “Digitalisation of the Supply”:

“Every professional working in Mental Health Departments, Family Health Clinics and Addiction Services must hold an exclusive computerised agenda within the Regional CUP system, or through a corporate IT platform managed according to the HL7 FHIR standard for interoperability purposes.”

This is not a generic aspiration. It is not a vague reference to “modern standards” or “digital transformation.” It is a binding operational provision embedded in a formally adopted deliberation by a Local Health Authority, naming HL7 FHIR explicitly as the required standard for local platforms that do not route through the Regional CUP.

Why this matters: context and significance

1. The Italian interoperability landscape

Italy’s national digital health architecture is undergoing a major transformation. The FSE 2.0 (Fascicolo Sanitario Elettronico, the national Electronic Health Record) initiative, driven by the PNRR (National Recovery and Resilience Plan), is building a centralised Ecosistema Dati Sanitari (EDS) — a national Health Data Ecosystem designed to aggregate and standardise clinical data from all regional health systems.

At the national infrastructure level, the FSE 2.0 Gateway validates and translates CDA R2 documents into FHIR for the EDS, but the document format flowing to the INI (Infrastruttura Nazionale per l’Interoperabilità) remains CDA R2. The only national service currently operating with native FHIR is the Piattaforma Nazionale di Telemedicina (PNT). This means that FHIR adoption at the local level — at the point of care, in the operational systems of individual health authorities — is still the exception rather than the rule.

In this context, an ASP formally prescribing HL7 FHIR as the interoperability standard for its local platforms represents a bottom-up adoption signal that complements the top-down national infrastructure.

2. The “invisible services” problem

Mental Health Departments, Family Health Clinics, and Addiction Services in Italy operate under a direct-access model: patients do not need a GP referral. This has historically meant that these services often function outside the CUP booking system, with appointments managed through paper registers, local spreadsheets, or standalone software with no interoperability layer.

The consequence is stark: services that do not produce structured, interoperable data become invisible to regional and national planning systems. Their workload goes unrecognised in official statistics. Their staffing needs are underestimated. Their funding is harder to justify. In a system where resource allocation increasingly depends on data-driven evidence, operational invisibility is an existential threat.

The PAGLA’s insistence that these services must either use the Regional CUP or adopt FHIR-based platforms is not merely a technological choice. It is a governance decision that brings these services into the structured data ecosystem, making their activity visible, measurable, and defensible.

3. FHIR as the “escape valve” for local innovation

The provision is carefully drafted. It does not mandate that every service must use the Regional CUP — which, in practice, may not yet be equipped to handle the specific scheduling workflows of mental health or addiction services. Instead, it offers a dual path: Regional CUP integration as the primary route, and FHIR-compliant local platforms as a legitimate alternative.

This is a pragmatic recognition that interoperability does not require uniformity of systems. It requires uniformity of standards. A local mental health platform built on FHIR can exchange data with the regional and national infrastructure just as effectively as the CUP itself — provided it adheres to the standard. The PAGLA codifies this principle at the operational level.

The dual-path model: Regional CUP as the default, HL7 FHIR-compliant local platforms as a standards-based alternative. This is interoperability governance done right — prescribing the standard, not the vendor.

4. A signal for HL7 communities across Europe

For those of us working in the HL7 ecosystem, the significance of this provision lies in where it comes from. This is not a national decree. It is not a ministerial guideline. It is not the output of a working group. It is a Local Health Authority in Southern Italy — a territory under a Regional Recovery Plan (Piano di Rientro), managed by an Extraordinary Commissioner, operating in one of the most resource-constrained areas of the Italian NHS — choosing to write HL7 FHIR into its operational governance.

This tells us something important about the direction of travel. When FHIR adoption moves from national infrastructure policy to local operational planning, it is no longer an aspiration — it is becoming an expectation. And expectations, once codified in formal acts, create institutional momentum that is difficult to reverse.

The broader PAGLA: not just about FHIR

It would be reductive to frame the PAGLA exclusively through the lens of interoperability. The document contains a wealth of operational provisions that address the waiting list crisis in the province of Cosenza with considerable specificity.

The waiting time data alone is sobering. The monitoring exercise conducted in early March 2026 across 69 tracked services revealed average waiting times of 263 days for a vascular surgery consultation (priority class P), 223 days for a simple electromyography, and 210 days for a sacrococcygeal spine MRI. These are not abstract benchmarks — they represent real patients waiting real months for care.

The plan responds with a multi-layered strategy: a newly established Waiting List Control Room (Cabina di Regia) chaired by a dedicated Waiting List Officer (RULA); strict separation between first-access agendas and follow-up agendas; a formal prohibition on specialists referring patients back to their GP for follow-up prescriptions; a “Waiting List” queue in the CUP system that triggers a formal care pathway guarantee when maximum waiting times are exceeded; extended opening hours including evenings and weekends; systematic audits of prescribing behaviour; mandatory CUP integration for all private accredited providers; and a rigorous monitoring framework with ex-ante and ex-post indicators.

The financial commitment is substantial: €8,644,960.98 allocated across public outpatient services (45%), private accredited outpatient services (20%), public surgical interventions (20%), private accredited surgical interventions (10%), and CUP back-office/front-office operations (5%). The plan estimates approximately 12,500 recoverable services based on a realistic assessment that draws on the lessons learned from the 2025 backlog reduction exercise.

What comes next

A plan, no matter how well drafted, is only as good as its implementation. The PAGLA itself acknowledges this: the territorial guarantee areas (Ambiti Territoriali di Garanzia) still need to be formally defined through subsequent implementing acts, in agreement with the Cosenza Hospital Trust (Azienda Ospedaliera Annunziata). The telemedicine component depends on the regional platform being deployed by Azienda Zero. The FHIR-based local platforms for direct-access services do not yet exist — they will need to be procured, built, or adapted from existing systems.

But the normative foundation has been laid. The deliberation is signed, published, and immediately enforceable. The expectation is codified. And for the clinical professionals working in mental health services, family health clinics, and addiction services across the province of Cosenza, the message is clear: the era of paper agendas is over, and the era of interoperable digital scheduling has formally begun.

From paper registers to FHIR-based platforms: the ASP of Cosenza has chosen to mandate interoperability at the point of care. The challenge now is implementation — but the institutional commitment is on record.

A personal note

I work as a Senior Clinical Psychologist (Dirigente Psicologo) at ASP Cosenza, in both a Family Health Clinic (Consultorio Familiare) and the Oncological Screening Unit. I also serve as Italy’s Ambassador for Hospitals on FHIR under HL7 Europe, and I am a member of HL7 Italia.

I have long argued — in this blog, in institutional letters, and at conferences including HIMSS26 in Las Vegas — that FHIR adoption in the Italian NHS cannot remain confined to national infrastructure layers. It must reach the operational systems where clinicians and patients interact daily. The fact that my own ASP has now written this principle into its waiting list governance plan is, for me, both professionally significant and personally encouraging.

The gap between policy and practice in Italian digital health is wide. But formal acts like this one narrow that gap, one deliberation at a time.