Strengthening primary health care through e-referral system.

Referral is a dynamic process, in which a health worker at one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the help of a better or differently resourced facility at the same or higher level to assist in. Health care systems of every country are designed in such a way to encourage patients to first attempt to get care at the primary level and then to approach a higher level of care according to the need. This protocol minimizes the costs for the caretaker/patients. However, in most of the countries, patients often bypass primary care facilities and directly go to the higher center thereby, increasing the burden on higher level facilities, the picture is not very different in India also. Health care system in India is plugged by: overpopulation, lack of expert clinicians, skewed distribution of physicians, lack of motivation among existing health care personnel and an ineffective referral mechanism. Due to failure of conventional paper-based referral systems in our country, we can introduce an e-referral system in the era of internet. It is evident from our experiences, that this artificial intelligence enabled e-referral system has many advantages over the traditional paper-based referral system. It will aid health workers for timely management of cases. Most importantly, it will streamline the existing unorganized referral process. Although, for effective e-Referral system, there should be a collaborative platform where easy search and discovery for health care providers is possible and help in decision making. e- Referral should be incorporated in our health system to strengthen it by bridging the access gap may be through Public Private Partnership model.

Introduction

In terms of health, World Health Organization (WHO) states that, “Referral is a process in which a health worker at one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the help of a better or differently resourced facility at the same or higher level to assist in.”[1] The obligation for having a sound referral system is important, to fulfil the existing gaps in Health Infrastructure. As there are only less than 20% of Sub-Centers, Primary Health Centers & Community Health Centers that meet Indian Public Health Standards; 80% of them fall short of Gynecologists, Pediatricians and Physicians.[2]

Global scenario

Worldwide, there are two major types of health facilities i.e. primary care facilities and hospitals in most of the countries. Health care systems of every country are designed in such a way to encourage patients to first attempt to get care at the primary level, and then to approach a higher level of care according to the need. This protocol minimizes the costs for the caretaker/patients.[3] However, in most of the countries, patients often bypass primary care facilities and directly go to the higher center thereby, increasing the burden on higher level facilities.[3]

Indian scenario

Likewise, in India, based on the need and availability of resources the patients are referred from lower to higher level and vice-versa [Figure 1], but at ground level, different scenarios are observed.

Figure 1

Referral systems in India

In reality, here, anyone can go to any level of healthcare facility for getting treatment irrespective of seriousness of his/her illness. This is mainly due to non-existent of any written policy for referral systems in India. Here existing referral system is not streamlined at all. Indirectly, this, exerts considerable amount of burden on higher level facilities as there is large number of Outpatient departments (OPDs) with patients of minor illness that can be managed at primary level. Health care system of India is plugged by: overpopulation, lack of expert clinicians, skewed distribution of physicians, lack of motivation among existing health care personnel and an ineffective referral mechanism.[1]

Review of literature has documented major causes of failure of traditional, paper-based referral systems in India which includes- lack of the skilled and motivated manpower, inadequate infrastructure, non-compliance on the guidelines meant for effective referral system, insufficient accountability to control unnecessary referrals at each level, inadequate back referral system of minor cases that comes directly to the higher level and absence of a universal health card.[1]

Referral is a dynamic system, it has inputs, processes and output component. As per management principles, if we have to increase in output without much investing on inputs, we have to improve our processes.[4] It is also evident from literature review that the paper based traditional referral system is existent on papers only. So, we have to use technology in the form of automation, to improve our processes. Now, due to the technological revolution through internet, artificial intelligence (AI) and mobile applications, it is very pertinent to incorporate these new technologies with existing process to improve our desired outputs.

E-referral is also known as “electronic referrals or electronic consultation” in which an electronic platform enables seamless transfer of patient information from a primary to a secondary treating practitioner's client management system.[5]

Working of e-referral

E-referralembedded with AI can make a huge difference in the existing health care system. Figure 2 describes the working of AI based e-referral system. Once, peripheral health workers input patients’ symptoms into the system, it gives the possible diagnosis, referral suggestions and opens up the communication channel with the higher health center. Hence, decision making becomes easier for the peripheral health worker for managing a case in a remote village and this is the advantage of e-referral over traditional paper-based referral system.

Figure 2

Flow of information through AI based Referral System

Online referral management system (ORMS) will not only save the initial golden hour but will also lead to decline in mortality. The ORMS will save unnecessary paper work in the hospitals. There will be real-time monitoring of the data entered by health workers on mobile phones and easy integration of data with the existing systems, e.g. HMIS along with cloud storage of patient records will also provide a dashboard window for State/Hospital/Department Health Activity statistics 24 × 7. The test reports can be exchanged online, that will bring ease in prior appointments and online prescriptions. Overall there will be a seamless integration with Public/Private Sector as patients reports/treatment from Private Sector will also be made shareable with Govt. Hospitals.[5]

In the long run, e-Referral will make easy discoverable referral options for Doctors (Specialists, location and OPD Timings), facilities, bed occupancy status and distance, timely communication, thanks to “Real time-Embedded technology.” This will not only help to better understand the disease patterns and existing problems but will also aid in policy decision making.[6]

Past studies have reported that in developed countries e-Referral has already led to improved communication, increased access to care, seamless exchange of information, improved knowledge management, decreased waiting times, fast, secure, and improved referral processes, reduction in unnecessary specialist visits, reduction in erroneous information, improved documentation quality, improved healthcare quality and significant reduction in administrative activities.[6]

One example of e-Referral in India is of “Jiyyo Innovations e-Referral System”. They collaborated Pediatric departments of 4 Hospitals namely Advanced Pediatric Centre, PGI Chandigarh, Government Medical College, Chandigarh, Civil Hospital Panchkula and Government Medical College, Amritsar. Results from e-Referral through “Jiyyo e-referral System” made 135+ referrals, 250+ messages exchanged between the referring and the referred side, 55 (Symptoms, Diagnosis) Tuples (a data structure consisting of multiple parts) Generated (For AI Algorithm Training) and it helped to streamlined the patient referral and improved outcomes from patients’ as well as physicians’ aspect.[7]

Conclusion and Recommendations

So, we can conclude that e-Referrals can reduce ‘DISTANCE’ between Periphery & the Tertiary Centers. Further, this will aid health workers for timely management of cases. Most importantly, it will streamline the existing unorganized referral process. Thus, for effective e-Referral System, there should be a collaborative platform where easy search and discover for health care providers is possible and help in decision making. Lastly, it should be universally accessible. e-Referral should be incorporated in our health system to strengthen it by bridging the access gap through Public Private Partnership model.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.