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e-Referral
Ministry of Health
Oman

The Problem

The process of Referral for specialized treatment or referral of investigations between the Primary Health Care (PHC) to Secondary and or Tertiary Care is a complex process. No only is the referral takes a long time to process, there is no feedback or acknowledgment if the referral documentation reach the intended referred institution. Even though the documentation for referral was produced from the computer systems, the process was completed manually. Fax machine or the normal mail system was used to deliver this documentation. The referral documentation was not standardized and for the investigation referral, important information like the laboratory tests name and range were also not standardized.

The minimum time for a referral to be processed was 3 days and there were no means to manage and control the Referral Process.

Solution and Key Benefits

 What is the initiative about? (the solution)
Thus the team in MOH initiated the e-Referral Engine. It involves first the streamlining of the Referral Process itself, deciding on the clinical documentation standard for referral for treatment and adopting standard for the investigation including, the name, code of investigation and the ranges and a decision to adopt SNOMED as a standard coding for Investigation. The first task was to well define the Referral Process itself and documented it appropriately. This was undertaken by the Directorate General of Health Affairs in coordination with the responsible for PHC, Hospitals’ Affairs and the management of healthcare institutions. The IT Unit then recommended adopting HL-7 V3 RIM for the Clinical Documentation, this was accepted. A Task Force of Laboratories representative from various healthcare institutions was created with a mission to standardize all the investigations and range and also to map it to SNOMED, which was selected as the standard to be adopted. Then an information system was developed consequently to meet these requirements.

There three immediate benefits to this initiative:
1. The speed of processing the referral – what used to take 3 days now takes seconds to process
2. The automated sending of feedback and
3. The Central and local management at each healthcare institution of the referral process.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The initiative of building the e-Referral Engine was initiated by the IT Unit of the Ministry of Health after several complaints from the various management of healthcare, specifically for:
• The lack of transparency in the Referral Process,
• The time it takes,
• The lack of feedback from referral,
• The error prone manual input of laboratory referral results at the referring institutions.

The development and implementation are always the role of the IT Unit of the Ministry of Health. The stakeholders were clinicians, Laboratory staff, and administrators, of concerned healthcare institutions organized in Task Force. The management of the Directorate General of Health Affairs, who defines and regulates the functioning of Health Services, chaired the Task Force.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main strategy is not to let the user felt that it is another new system as it is human tendency to be less responsive to change. As Al Shifa HIS (Hospital Information System) is already implemented in most healthcare institutions belonging to the Ministry of Health, it was easy to include the e-Referral application as an add-on component on each installation and then a central Engine to route the referrals to desired destination at the same time building the necessary information for the central management and local management at each institution. The objectives of this initiative were to:
1. Create transparency in the Referral Process, so it can be properly manage and audit.
2. Reduce drastically the process time
3. Eliminate error prone manual data entry
With the experience of implementing Al Shifa HIS, the implementation of the e-Referral follows the successful route of getting users involvement and training.

The Directorate General of Health Affairs is the one that defines and regulates the healthcare processes and anything in these lines has to approve by them. However for any important decision it coordinates with all the stakeholders.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The initiative had to be approved by the Directorate general of Health Affairs, which created Task Forces to re-engineer the Referral Process, to standardize the Laboratory investigations and give the go-ahead to the IT Unit of the Ministry to start the development and then to train the end users in each healthcare institutions and centrally at the Directorate General of Health Affairs. The Laboratory Task Force was requested to establish a framework of introducing new laboratory tests, as it would be maintained centrally and the facility of adding manually new lab. Test was taken from all the institutions.

The Initiative started in 2007 and by 2009 the application was installed in all healthcare institutions of the Ministry of Health.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The main obstacle was for healthcare institutions to accept the laboratory framework of central management. For the sake of maintaining and protecting standard the Directorate general of Health Affairs was firmed on this Initiative.

A smaller obstacle came from the specialized clinics, where they will be accountable for the delay in giving appointment and also the feedback. To make it easy, the initial feedback has been automated without putting any extra workload to the clinicians. The IT Unit also simplified the feedback to be simpler and easier.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
All the resources are in house there is no additional hardware needed and the development was done totally by the in house IT team. The cost is only salaries the Ministry is already paying for each of its employee working in this Initiative.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
Because the expertise in Medical and IT fields are from the Ministry of Health own internal staffs, the issue of sustainability and transferability take a complete different dimension in criticality. There are time to time some resignations of medical and IT expertises but always replacements are brought in and these have never be a serious treat to the continuity of Health Information Technology (HIT).

The system is also highly scalable and can be customised for another organisation

Lessons Learned

 What are the impact of your initiative and the lessons learned?
A well planned introduction of Health Information Technology (HIT) in healthcare institutions pays. The initiative is successful; the healthcare institutions can hardly operate appropriately without it. It has created transparency and management capability in the Referral Processes and the time gained is tremendous, especially for treatment referrals. It use to take a minimum of 3 days, while with this Initiative is barely taking few seconds. It get concluded while the patient is still with the referring clinician, who then print and hand over the Referral Notification to the patient at the same time an SMS is automatically send the patient GSM.

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Government Agency  
Contact Person:   AbdulRahman Al Touqi
Title:   Director General of Information Technology  
Telephone/ Fax:  
Institution's / Project's Website:  
E-mail:   dg-it@moh.gov.om  
Address:  
Postal Code:  
City:  
State/Province:  
Country:   Oman

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