# Ensuring the Long-Term Preservation of and Access to the Italian Federated Electronic Health Record
## 4 Results  
The main result of the present study coincides with the formalization of the efficient and enhanced use of the indexing and preservation metadata in the FSE registry, which allows for guaranteeing the correct document workflows and long-term access to reliable resources, even if different stakeholders are involved. The two proposed flows relate to the metadata communication: (i) in case of creation of a new document, and (ii) in case of metadata updating of an already indexed document. They can further differ depending on whether the document is about a patient in its RDA or in RDE. These flow charts, regarding the description and modeling of activities and related areas of expertise, are a simplified version of the metadata communication flows, which are part of the services offered by the INI [28]. In the following flow charts, the process step in which the registration of indexing and preservation metadata should be performed to correctly play its role is highlighted. In particular, the metadata communication process regarding the creation of a new document for a patient of the RDA (Figure 2), involves the RDA, the INI and the National Register of Assisted (hereafter ANA), and it starts with the request by a health professional, through the regional system, sent to INI, which carries out the validation of the patient. In this case, in addition to the indexing metadata, the preservation metadata can also be registered during the metadata communication about a new document task, if the document submission to the preservation system of the healthcare facility and its indexing in the FSE registry are contextually performed, whereas if the submission of the document to the preservation system is subsequent to its indexing in the FSE, the preservation metadata registration should be performed within the metadata communication regarding document updating for the patients in the RDA (Figure 3). In the case of a patient in the RDE, within the metadata communication process on the creation of a new document, the RDE communicates to the RDA, through the INI, the metadata to index the document in the RDA registry (Figure 4). It starts with a request sent by the RDE to the INI, which requests the ANA to validate the patient and to identify his/her RDA. The INI communicates the new document metadata to be included in the registry to the RDA. Finally, the RDA returns to the INI the outcome of the insertion of the metadata of the new document in the FSE of the patient, which is notified to the RDE. Figure 2: Metadata communication process about the creation of a new document for a patient in the RDA. Figure 4: Metadata communication process on the creation of a new document for a patient in the RDE. Figure 3: Metadata communication about document updating for a patient in the RDA. As in the process in the RDA, in the metadata communication process regarding a new document for a patient of the RDE, in addition to the indexing metadata, the preservation metadata is registered during the metadata communication regarding the new document task, if the document submission to the preservation system of the healthcare facility and its indexing in the FSE registry are performed in the same step. Conversely, if the document submission to the preservation system is performed after its indexing in the FSE, the preservation metadata is registered during the metadata communication regarding document updating for a patient in the RDE process (Figure 5). The flows could be further integrated or revised after a survey with the stakeholders, which will be the next step of the study. At the current stage of the research, the following outcomes can be highlighted: (i) the possibility of guaranteeing authenticity, integrity, reliability, readability, availability of the  
Figure 5: Metadata communication about document updating for a patient in the RDE. FSE documents over time, as required by the Guidelines; (ii) a non-impacting solution on the current FSE regional systems.