Questions/Answers

Bhumibol Adulyadej Hospital distributes the assigned Universal Health Coverage (UHC) patient to receive primary care at network clinics in their neighborhood and forwarded to the hospital for secondary and tertiary services if necessary. The patient referral protocol usually faces communication problems, namely lacking of critical patient information and case urgency. This potentially leads to errors in referring patients to specialists outside the field of disease. Successful action must ensure a thorough inter-agency coordination and timely access to appropriate specialist care. BAH and stakeholders are aware of this challenge and developed e-Referral Healthcare System to solve the communication problem by (1) collecting patient information, (2) analyzing the problem together with all relevant sectors, (3) solution planning and determining budget responsibility, (4) providing technical support, database development, and digital cloud deployment for the hospital and private clinics, (5) executing the plan (6) monitoring, evaluating and having a system to coordinate and solve problems continuously. The operation process between the network clinics and the hospital may provide effective services for patients. However, the patient might have not received their important health information related to their medical treatment, therefore, a mobile application was developed to provide patients with crucial real-time health information. In addition, patients can also make appointments through the application to increase patient convenience. The physicians and medical staffs can receive real time information that enhance decision-making and work efficiency. Although many countries, such as Canada, have been successful in the e-referral operation, the unique e-referral system in Thailand build trust in quality of care by developing guidelines for personnel at all levels of the network clinics, establishing practices and referrals of quality pregnancy care and chronic diseases, monitoring the network clinics, establishing a consultation channel for a specialist clinic as well as evaluating and exchanging the Best Practice in the network.

It is in line with branch 1 by promoting innovation to deliver comprehensive and equitable services as well as enhancing digital transformation. The E-referral Health Care System Project at Bhumibol Adulyadej Hospital is a project of a government agency to develop services in order to achieve the goals of the SDGs item 3. This project is to ensure the public well-being and to promote welfare for all people of all ages, because it is a project that encourages people to access health services by increasing an efficient of forwarding information system and applying central database technology.

The development of the primary care system using the Primary Care Trust model at Bhumibol Adulyadej Hospital is supported by Royal Thai Air Force and national agencies. The National Health Security Office (NHSO) has announced the policy and continued budget support from 2013 – 2021, amount to 62,000,000 baht for the development of a prototype information system for referring patients of the National Health Security System in Bangkok, concurred with United Nations announcement on topic 3.8, the achievement of universal health coverage including financial risk prevention and access to essential quality, safe and efficient healthcare. Besides, the technology selected has a certain design and is easy to de-velop. It can be used on the basis of information system for every service unit in the most cost effective way. That will result in a simpler processes, simplified service and an increase in clinical outcomes of patient care to raise operational standards.

The model is comprise of systematic collection of patient information, using patient data to assess the severity of the patient's condition to forward appropriate treatment and increasing effective communication. In addition, Royal Thai Air Force has signed a Memorandum of Understanding on the project to develop referral information systems including the matter of seamless inter-hospital treatment, which is expected to become a global future priority.

This project is to support collaboration between government and private sectors in order to reduce the congestion in providing the Universal Health Cover Project service. The project is also to support patients who need specialists’ treatment at a hospital for an effective care by using patient information via a clear communication system to support the decision-making of medical treatment plans.

b. The project is to effectively and efficiently provide patients of all age groups an access to all medical treatments.

The project supports more than 150,000 people. The hospital can reduce the congestion of primary care recipients. The Statistics illustrate good clinical outcome: the referral rate to the hospitals was around 10-15% of clinical chronic disease cases. The hospital admission rate for diabetes with renal complications was 1%, and for hypertension was 0%. In the care of pregnant women, those who received the service were found to be able to take care of the specified standards of 85% or more. In 2018-2019, the newborn infants and mothers are 100% safe. In addition, the project improved the healthcare services while saving patients 78,178 trips a year to get referral document from the clinic by: Safe patient’s 3 hours for obtaining a referral document from the clinic amounting to a total of 234,534 hours annually Eliminate 300 baht transportation cost to the clinic totaling 23,453,400 baht annually reducing 77 minutes patient waiting time for document examination at the hospital totaling 100,328 hours annually promotes paperless the process which saves 5 sheets, totaling about 400,000 sheets or 150,000 Baht annually Increasing the consistent and quality of medical treatments due to the sufficient database of the patient's continuing medical history.

In 2001, the universal health insurance system assigned 200,000 people to the care of BAH. At first, there were 500 OPD cases/day which was a burden on the hospital resources. Therefore, in 2006, a new service model was created by distributing over 150,000 people to 27 primary private clinics so the patients could receive primary care in their neighborhood and reduce overcrowding in BAH to 30 OPD cases/day. BAH was responsible for systematic quality control of network clinic service, starting from building relationships among personnel within the network, developing human capability at all levels and providing referral services to network clinics in case it exceeds their capacities. However, patients wasted more than 1-2 hours waiting and transportation fee of 300-400 baht just to get referral document in each referral which amounts to 70,000-80,000 referral per year. In 2013, BAH developed an e-Referral Healthcare System to reduce the bureaucracy. The clinic will send patient information through IT and the patients could contact the OPD directly. As a result, the service waiting time was reduced to 30 minutes. In 2014, BAH developed the Primary Care Trust model which paid attention to providing care for NCD patients and pregnant women. BAH also provided a medical consultation system and a system to continuously monitor and evaluate the network clinics every year. It was found that 10-15% of hospital OPD cases are referred patients and there was low admission rates for diabetes with renal complications, and hypertension complications. For the care of pregnant women, the newborns and mothers are 100% safe. In 2018-2019, the hospital developed the e-Referral Healthcare System to sync patient information through a mobile application. In addition, patients could also make appointments through the application. It was found that there were more than 5,000 downloads.

Over 150,000 people were distributed to 27 network private clinics for primary care services. Nevertheless, there were communication problems between the network private clinics. The quality and practice of clinical primary care services were also not consistent. In 2013, most patients did not have confidence in the e-Referral Healthcare System. The users of the system also lacked of IT knowledge. Besides, there was an unstable information system. In 2019, BAH developed a system via mobile applications which allowed patients to see important information such as treatment, Lab, X-rays, diagnosis, procedures, and vaccine information.

The e-Referral Healthcare System is a radical change to the referral system because it is the first pilot of an information forwarding system in Bangkok. The system provides clinical network and hospital staffs with patients’ treatment information in real time, together with the use of application BAH Connect for appointment reminder and to access personal medical history. Subsequently, patients who need a chronical care from the specialized doctors of Bhumibol Adulyadej Hospital are cared for quickly, conveniently and efficiently on a budget.

The Primary Care Trust model is introduced to the development of the primary system which consists of the use of knowledge development to guide all levels of the network clinics, establishing practices, referring quality pregnancy care and chronic patients. In addition, there is a regular clinical supervision and monitoring team. The hospital also establishes a consultation channel for a specialist clinic as well as sets a team tasking with the evaluation and exchange of Best Practice in the network. This is because supporting network clinics as a part of the hospital is a guarantee of good quality of services.

The e-Referral Healthcare System has the potential to expand across the country. It can be easily adapted ability to connect with a variety of hospital information systems both domestic and international. The system has been designed to emphasize the importance of delivering good services to patients by providing a seamless end-to-end process between hospital and network clinics, also establishing guidelines for care and referral criteria. As a result, the network clinics have been improved together with providing appropriate care and increasing safety for patients. Additionally, the system allows patients an easy access to medical services and reduces the communication gap.

The e-Referral Healthcare System has been expanded to both public and private hospitals in Bangkok and suburbs. The knowledge of the system has been transferred in many forms, including lectures and seminars. It is a source of study tours both at domestic and international such as the delegation of the 56th Prince Mahidol Award International Symposium, Asia eHealth Information Network from the Republic of the Union of Burma, Bill and MelindaGates Foundation India Office, Faculty of Medicine from Turkey, Faculty of the Asian Universities Alliance-AUA, the delegation of the 63th Prince Mahidol Award International Academic Conference (PMAC2020).

As mention previously, the knowledge of the e-Referral Healthcare system has been transferred in many forms, including lectures, seminars, symposium and International Conference.

The E-referral Health Care System has been supported by the Air Force and national agencies. The National Health Security Office (NHSO) has announced the policy and continued budget support from 2013 - 2021 with the amount of 62,000,000 baht for the development of a prototype referral information system in Bangkok.

The hospital executives provide operational support such as operational personnel, location and necessary equipment. Sustainability of the operation is from having a networked care system in which the hospital offers to support the improvement of personnel covering all important matters. There are also many convenient channels for the clinical consultation via telephone and social network.

Yes

In 2014, the E-referral Health Care System has been assessed by NHSO as an agency that has developed the quality of primary networks in the rank of "Outstanding level".

The E-referral Health Care System have been applied in Bangkok, resulting in over eight referral networks across Bangkok, in order to support over three million people. This is because E-referral communication is conducted in a systematic and standard way which is fast, accurate, real time, and paperless.

The E-referral Health Care System is a radical change to the referral system. It is a pilot information system in Bangkok. All of service patients who need to receive chronical care from the specialist physicians of Bhumibol Adulyadej Hospital do not have to deliver referral documents from the network clinic to the hospital. Around 95% of these patients information can be sent to the system. Although, there are 5% of the patient's data which cannot be transmitted through the system, the E-referral Health Care System has also designed to coordinate within the network without affecting the patient's service. As a result, the waiting time was reduced to 30 minutes. Clinical, networked and hospital medical personnel are able to see treatment information in real time. In October 2019, the development of application BAH Connect has been introduced as a reminder for patient appointments and access to personal medical history. Currently the application has been downloaded over 5,000 times.

The E-referral Health Care System received cooperation from the following sectors. Bhumibol Adulyadej Hospital initiates the use of digital information system and develops knowledge and human resources. Network Clinics follow up and evaluate the system to coordinate operations both vertically and horizontally. Region 13 of the National Health Security Office supports the budget and acts as an administrator and a consultant to fix the system when problems occur. National Electronics and Computer Technology Center (NECTEC) is the developer of the referral information system. The E-Government Office provides technical support and database via the cloud. Private network clinics initiate the use of digital information system and gather information and problems to inform the relevant units.

The first step is a consultation process from stakeholders by listening to the issues in order to meet all demands. Then, stakeholders shall recognize the importance of cooperative interaction to improve individual productivity. This allows stakeholders to realize that collaborative work is a valuable way of working in order to solve problems that have a wide impact on people.

Bhumibol Adulyadej Hospital needs to integrate service, starting from the establishment of a primary care network, and support the network by developing the primary care service using the Primary Care Trust model, together with developing e -Referral Healthcare System or Mobile Application. The Primary Care Trust model focuses on caring for patients with critical disease to receive service without complications, including NCD disease and pregnant women. This is to ensure that the quality of the service units in the network is good and up to standards with the final goal of building confidence or trust in people who receive services. All the above can be achieved by executives with policies to support all aspects of operation, clinical network that focuses on working together to achieve the goal and most importantly, cooperation from all government and private sectors. Besides, Bhumibol Adulyadej Hospital plans to develop e-payment system, drug delivery by mail and VDO call system, which will enable the patient care system to be fully integrated and reduce congestion in the hospital.