There are many definitions to the term ‘medical referral system’ by a variety of authors and scholars. A referral system, according to Almalki, FitzGerald and Clark (2011) is an institutional framework that comprehensively connects a variety of entities that have different responsibilities and duties into one network. Another definition by MOH (2016) posits that a referral system in healthcare is the “process of directing or redirecting the patient to the optimal level, usually from the lower potential levels to the greatest potential ones ensuring the access into the right care, at the right time, in the right setting, by professional medical staff”. The healthcare system is composed of a myriad of components, each with varying mandates and responsibilities, although sometimes, overlapping.
The first contact for patients in healthcare is primary level care services. However, the resources and expertise available at this level may not be sufficient to handle the medical situation of a patient, which calls for referral into a secondary or tertiary level care facility. In Saudi Arabia, the referral program used to facilitate the process of referring patients from lower level care facilities into higher levels of care is referred to as Ehalati. In the recent past, Saudi Arabia has experienced tremendous changes in the provision of care services in the public health sector. The purpose of this paper is to analyze the effectiveness of Ehalati, and this will be achieved through a literature review of other referral systems, and comparing them to Ehalati. This evaluation will illuminate the challenges and facilitators of referral in different countries, in comparison to the referral system in Saudi Arabia.
Ehalati
Almalki, FitzGerald and Clark (2011) observed that in the recent past, the Kingdom of Saudi Arabia has developed measures intended to improve the provision of care at primary, secondary, and tertiary levels. The government gives priority to healthcare services, and provides free access to all servants working in the public sector. Not only has the healthcare services improved in terms of quality, but also in terms of quantity. The improvement in care facilities in Saudi Arabia has significantly improved the quality of life of Saudi Arabians. In fact, the significant improvements in the healthcare system of the Kingdom of Saudi Arabia have facilitated its ranking as the 26th out of 190 health systems in the world. Included in these improvements is the referral system of the kingdom.
The Ministry of Health of Saudi Arabia mentions the referral program, Ehalati, as the backbone for connecting basic medical care and the hospitals. The ministry defines a referral system as the “process of directing, redirecting or transferring, a patient to the appropriate specialist or agency”. Referral occurs when a patient is redirected or transferred from a less complex organization, to one with a higher resolution capacity. Referral can either be vertical or horizontal. Vertical referral is characterized by the redirection of patients from lower units to more complex units in the same facility. Horizontal referral occurs when the patient is referred from a lower capacity unit to a more complex unit in a different organization.
Variations to the referral system have been made over the years, with the aim of improving the experience of patients with the system (Almalki, FitzGerald & Clark 2011). The variations focus on improving the quality of care services, while ensuring patient satisfaction with the system. To improve the quality of referral services, the government has implemented policies and regulations to govern the referral processes. The policies not only outline a legal framework, but also provide care professionals and patients with a framework to guide decision making. The system also utilizes the latest techniques and capabilities to connect service providers with the beneficiaries of these services, which consequently enhances the logistics required to improve performance of the referral system.
Literature Review
This literature review was achieved after a systematic search from major websites such as PubMed, Medline, and Google Scholar. The search was limited by key search words including ‘medical referral systems’ ‘medical referral systems in Saudi Arabia’, ‘ehalati’ ‘role of medical referral system’, and ‘medical referral system in Saudi Arabia’. The search gave rise to a variety of journals and articles, all in varying capacities to facilitate the review of literature, and the most relevant was selected for this purpose.
Al Jamaan et al (2014) designed a research study that sought to evaluate the referral system for cancer patients and the information they received about their health conditions in tertiary hospitals in Riyadh. The cross-sectional study involved 73 participants from two different hospitals in Riyadh. The participants were men and women who had been diagnosed with cancer and had received tertiary treatment for any time period. 44.8% of the participants had been referred, while the rest were admitted without referral to the two hospitals.
The study shows that tertiary care facilities do not necessarily receive patients who are on referral, but also patients who are admitted directly. However, the study didn’t evaluate the experience of the patients with the referral system, which is also a focus of this study. The study was well designed, which is a merit for the study. There is no concurrent research on the same topic researched by this article. This implies that the findings of the study haven’t been replicated in other studies, which discredits the merit of the study in terms of reliability. A good study design should be replicable and generalisable.
The improvement in the referral systems in Saudi Arabia has greatly been facilitated by the extensive use of technology in the health sector of the country. Technology facilitates the mode of communication between primary health centers and the referral hospitals. However, despite the great improvements to referral processes from primary care to tertiary care, there are many challenges that mar the process. For example, there is no clear implementation strategy for enforcing the use of e-referral systems, while most staff members lack the relevant computer skills to handle electronic referral systems. A case study by Alshami, Almutairi and Househ (2014) reports the experiences of implementing electronic referral system – Ehala – in a local Saudi hospital.
The e-referral system was a complex information system comprised of more than 300 primary health centers and 40 hospitals. The results from the case study indicate that KSHCD, the local primary health center, has greatly benefited from the e-referral system through improved communication between the PHCs and the hospitals. The improved communication has consequently contributed to enhancement of the continuity of care for the patients.
Another study by Al-Alfi et al. (2007) sought to evaluate the quality of referral letters and feedback reports that adhered to standards of quality assurance manual as outlined by the Ministry of Health from primary health care centers in Buraidha. The results indicated that most of the referral letters lacked important information such as the history of the patient, the vital signs, results of basic investigations, and the results of clinical investigations. The standards of quality demand that all relevant information about a patient is included in the referral letter, as this aids the receiving hospital to make informed decisions regarding the type of care that the patient should receive.
The research was a well-designed study that used random selection of the referral letters as a means of eliminating the risk of biasness. However, these shortcomings have since been overcome through the use of electronic version of referral letters, which have not only eliminated the risk of omissions, but also that of wrong entries into the referral letters. It is not evident from the study whether the primary health care centers fully utilize their resources before referring a patient for tertiary care. The results of this study are echoed by those of Abdelwahid, Al-Shahrani, Elsaba and Elmorshedi (2010), who sought to evaluate the referral patterns in family medicine, and the appropriateness of the referral letters and the feedback of the consultants.
The cross-sectional study that was carried out in family medicine department of the Sharurah Armed Forces Hospital revealed a 16% referral rate. The study found that administrative variables of the referral letters were better represented compared to the clinical variables. Also, the study revealed that the rate of inappropriate consultant letters was higher compared to the rate of inappropriate referral letters. These occurrences are evidence that the quality standards of the referral process are either not being adhered to, or require significant improvement.
Al-habib, Jamjoon and Elgamal (2012) posit that some of the most common challenges facing referral systems in most countries are limited availability of special care centers, accessibility to care, and lack of an established referral system. The study by Al-habib, Jamjoon and Elgamal sought to outline the referral process for neurosurgery cases in one of the hospitals in Riyadh, Saudi Arabia. The referral process is fundamental in achieving the effectiveness of referring a patient from primary care to tertiary healthcare facilities.
The prospective observational study revealed that the referral process was marred by challenges such as lack of availability of the neurosurgeons, insufficient information accompanying the patient, and lack of beds for the referred patients to the tertiary facility. However, the authors of this study indicate that the sample was too low to inform a sufficient decision regarding the process of referral in the Kingdom of Saudi Arabia. They posit, however, that the research was necessary in developing a gap for further study into the causes of delay when patients are referred to tertiary hospitals.
The above review of the literature indicates that although the referral system in Saudi Arabia is one of the best in the world, it is still not perfect, as the quality standards for referral are sometimes overlooked by the referring staff members. However, these discrepancies are not as a result of poor design of the system, but rather, the implementation of the referral systems across various hospitals. Lack of skills among members of staff on how to effectively complete a referral letter is conspicuously revealed in two studies. In addition to incomplete referral information, another difficulty that patients in Saudi Arabia may encounter when being redirected from a primary care setting to tertiary care setting is the unavailability of beds or space in the tertiary hospitals.
Almalki, FitzGerald and Clark (2011) posits that the Saudi Arabian healthcare system is one of the most effective, providing free care services to more than 60% of all the Saudi Arabians. This implies that the services are sought after due to the accessibility of the services, and has the potential to overload the healthcare systems if the necessary adjustments are not made to accommodate the population and the changing population needs. Also, the studies do not indicate if patients receive optimum care at the primary care level before they are referred to tertiary care facilities.
The review of the Saudi Arabian healthcare system, however, reveals that the primary care facilities are well equipped with the relevant facilities to facilitate optimum care of patients before referral. Also, the referral system by the Ministry of Health of the Kingdom of Saudi Arabia requires various procedures to be followed before the initiation of the referral for any patient. These procedures ensure that the patients receive optimum care, and are only referred because the primary care lacks the adequate resources to handle the health condition of a patient.
One significant feature of the Ehalati referral system in the Kingdome of Saudi Arabia is its ability to enhance cost effectiveness and maximum utilization of hospital facilities and resources. The electronic referral system is especially essential in reducing costs, as information about patients can be exchanged effortlessly and in a safe and effective manner. One of the main goals for the implementation of the electronic referral program was to ensure better utilization of resources.
Maximum utilization of resources ensures that no resources are underutilized while at the same time eliminating biasness in distribution of the resources. Therefore, it is safe to say that the referral system ensures that all health services, including secondary services, are effectively utilized for the provision of optimal services to the patients before a referral to tertiary care facilities is requested. Despite the improved healthcare system in Saudi Arabia, it is still prone to challenges such as shortage of medical professionals, the multiple roles played by the ministry of health, high demand of services because they are free, and the ever changing nature of diseases and illnesses, which demand for huge investments in order to keep up to date with the changes.
Conclusion
In conclusion, the medical referral system of the Kingdom of Saudi Arabia – Ehalati - has been described by various researchers as one of the best referral systems in the world. This is due to the ability of the system to facilitate the seamless and effortless transfer of patients from one level of care to another, which has greatly reduced the mortality rates associated with delay of the right care to patients. In fact, the framework of this referral system has been used by other Ministries of health in other countries to inform development of an effective model.
This paper carried out a literature review on the process of referral in Saudi Arabia, which revealed that although the referral system is feted in the country and beyond, there are still various challenges that threaten its integrity. Insufficient finance is a major threat, as the care system is overburdened with the many people that seek medical services. Despite these challenges, the healthcare system in Saudi Arabia, and notably its referral system, still manages to remain among the top best providers of care services to their citizens.
References
Abdelwahid, H.A., Al-Shahrani, S.I., Elsaba, M.S. and Elmorshedi, W.S., 2010. Patterns of referral in the Family Medicine Department in Southeastern Saudi Arabia. Saudi medical journal, 31(8), pp.925-930.
Al-Alfi, M.A., Al-Saigul, A.M., Abed-Elbast, A.M., Sourour, A.M. and Ramzy, H.A., 2007. Quality of primary care referral letters and feedback reports in Buraidah, Qassim region, Saudi Arabia. Journal of family & community medicine, 14(3), p.113.
Al-Habib, A.F., Jamjoom, Z.A. and Elgamal, E.A., 2012. Pattern of patient referrals to a tertiary neurosurgery center in the central region of Saudi Arabia. Neurosciences, 17(3), pp.271-273.
Al Jamaan, M. A. et al. 2014. Evaluation of Referral System for Cancer Patients and The Information they received about Their Disease in Tertiary Hospitals in Riyadh, 2012. World Family Medicine Journal: Incorporating the Middle East Journal of Family Medicine, 12(5), pp.26-33.
Almalki, M., FitzGerald, G., & Clark, M. 2011. Health care system in Saudi Arabia: an overview/Aperçu du système de santé en Arabie saoudite. Eastern Mediterranean Health Journal, 17(10), pp.784.
Alshami, M., Almutairi, S. and Househ, M.S., 2014, July. The implementation experience of an electronic referral system in saudi arabia: a case study. In ICIMTH (pp. 138-141).
Ministry of Health. 2016. Referral Program. Retrieved from MOH KSA database
Ministry of Health, Kingdom of Saudi Arabia. 2016. Referral program (Ehalati). Retrieved from http://www.moh.gov.sa/endepts/Referral/Pages/default.aspx
