Construction and practice of medical alliance referral system based on blockchain / 中华医院管理杂志

Hierarchical diagnosis and treatment system is an important measure to rationally allocate medical resources and promote the homogenization of basic medical services. The medical alliance is an important service mode and service system of hierarchical diagnosis and treatment, whose role is to perfect the up-down linkage and meet the patient′s medical needs. Informatization construction is an important starting point to promote the services of the medical alliance. In order to solve the problem of connectivity, the medical alliance needs to establish a regional referral platform and realize the integrated service of all medical institutions. Renji Hospital, Shanghai Jiaotong University School of Medicine, has built a blockchain based referral system for hierarchical diagnosis and treatment, incorporating the S2B2C mode concept, and using the traceability, tamper proof and distributed accounting features of blockchain technology, realized independent storage of data in hospitals, realized real-time information sharing and interconnection, and provided a feasible solution for medical alliance management.

Cardiac rehabilitation referral service (review) / 中国康复理论与实践

@#Objective To summarize the cardiac rehabilitation referral system.Methods The literatures about the construction of cardiac rehabilitation referral systems were retrieved from the databases of CNKI, Wanfang Date, PubMed and Web of Science, and cardiac rehabilitation websites.Results For some foreign countries, the referrals of cardiac rehabilitation mainly based on electronic medical record management system, internet platform, chronic care model, and hospitals and communities. For China, referral system is trying to build based on the medical conjoined system.Conclusion Referral, as the first step, plays an important role in participating in cardiac rehabilitation for patients. The cardiac rehabilitation referral system needs to be improved in China, referred the ways of developed countries.

Expanding access to viral load testing in Nigeria; the impact of third party logistics

Background: Access to viral load testing in Nigeria remains a key challenge in achieving the Joint United Nations Program on HIV/AIDS (UNAIDS) 90:90:90 targets in the fight against HIV/AIDS. This study investigates the impact of 3 party logistics (3PL) on expanding access to viral load testing.Methods: This exploratory, case study research was carried out in Abuja in December, 2018, using in-depth interview method. Open-ended questions were used to interview nine staff from the three polymerase chain reaction laboratories in Federal Capital Territory. The audios of interviews were recorded and transcribed on paper. The data was analyzed using SPSS version 24.Results: This study revealed that the adoption of 3PL services has helped to overcome major challenges of viral load testing such as late delivery of samples, late collection of results, and rejection problems; thereby reduced sample rejection frequencies, increased efficiency, reduced turnaround time and ease viral load testing processes. Though the adoption of 3PL has helped to overcome major challenges of viral load testing, however, the challenges still facing viral load testing include the 3PLs bringing samples at any time-even at closing hours, not delivering results to facilities on time after pickup, poor medical backgrounds and inability of 3PLs to enforce instructions on facilities. However, respondents expressed satisfaction with the services of the 3PLs.Conclusions: The findings of this study revealed that the adoption of 3PL service into viral load transport logistics has positive impacts on the process. However, only one of the laboratories uses two 3PL providers while other two use only one.

Barriers to an Effective Maternal Health Service Delivery Network: A Qualitative Study among Health Providers in Legazpi City, Albay

Objectives@#To A functioning referral system is critical to the maternal health program, especially in the management of obstetric emergencies. This study explored supply-side barriers affecting the effective implementation of the said service delivery network (SDN) in Legazpi, Albay in the Bicol Region of the Philippines. @*Methods@#Face-to-face in-depth interviews using semi-structured questionnaires were performed with health care providers involved in the SDN in Albay. Extensive note taking was done by the primary investigator while participants were observed during performance of duties from June - November 2018. Interviews were audio-recorded, transcribed, translated into English, and analyzed thematically along with the observation notes using NVivo. A deductive-dominant approach was utilized for the data content analysis.@*Results@#Referral system barriers identified were cross-cutting across the different components of the health system such as governance, human health resource, service delivery and information systems. The barriers were further classified into individual, organizational and external-related factors in relation to the SDN. Examples of barriers included lack of knowledge of protocols and guidelines, lack of coordination between facilities, poor data management, inadequate capacity building opportunities, and constantly changing political landscape and policies.@*Conclusions@#The study is the first to explore barriers to effective service delivery network in maternal health in the country. Findings from the study provide significant insight to areas of improvement in the SDN that must be addressed to strengthen local health systems, especially with the country’s movement towards Universal Health Care where local health systems play a key role.

An Insight about the Referral System in Health Care Network: Flaws with Recommendations for Improvement

Healthcare network is composed of primary, secondary and tertiary care centers. Purpose of each unit in this sophisticated zone is to allow steady and smooth delivery of healthcare to optimum level without wasting essential resources or time. If, primary care centers are not able to fulfill the needs of any health issues then, patients are referred to more advanced setup where their health issues can be timely addressed in a proficient way. Referral system forms an important component of healthcare network and it should be formulated in such a way that it can bring fruitful results with the proper use of time, energy, man force as well as technical resources without compromising patient’s health. In this paper, we discussed the core of healthcare network in the city, working with primary as well as referral health care centers, flaws affecting the referral system and recommendations to improve them.

Predictors in profile of referred newborns for their outcome in a tertiary newborn referral facility

Background: This study was aimed to assess newborn referral and factors contributing to outcome of referred newborns.Methods: This prospective observational study was conducted in a tertiary newborn referral facility for a period of one year. Referred newborns fulfilling inclusion criteria were enrolled in study, and assessed in terms of demographic profile, transport characteristics, physiological variables. Investigations, management of neonatal illness was done as per standard management protocols, they were followed up to their outcome.Results: Out of 2000 enrolled referred newborns, 30.10% were expired. Mean gestational age for survived newborns was 36.54'2.92 (SD) weeks, for expired newborns 35.24'3.99 (SD) weeks. Mean weight for survived newborns 2312.27 gms '555.71 (SD), for expired newborns 1936.71 gms '665.67 (SD). Out of total 60.05% newborns transported from periphery, had higher mortality i.e. 35% as compared to newborns transported from urban place i.e. 25%. Mean transport duration for survived newborns 61.94 minutes '55.18 (SD), for expired newborns 89.51 minutes '88.94 (SD). Prolonged CRT was observed' in 57.45% newborns, grunting'' 19.70%, Cyanosis 11%, gasping 7.6%, apnea 5%, respiratory distress 39.80%, hypothermia 74.95%, and 25.50% required resuscitation on admission. Unattended delivery, self-arranged mode of transport, prolonged CRT, respiratory distress, apnea , hypothermia on admission, weight on admission(<1500gms), hypoglycaemia and duration of transport more than 1 hour' found statistically significant independent variables associated with mortality of referred newborns.Conclusions: A significant number of neonatal deaths can be prevented, if referral system is structured and organized. Improper referral leads to poor physiological profile of referred newborns, which leads to their poor outcome. There are many independent variables which are affecting the outcome of referred newborns. These independent variables can be taken care in holistic way once the referral system is cultured and nurtured in existing health system.

Exploration on impacting factors for restricting two-way referral system from patient's perspective / 重庆医学

Objective To explore and discuss the factors for restricting the two-way referral system from the patient's perspective in order to promote the formation of hierarchical medical system in Changsha City.Methods The stratified random sampling method was adopted to divide the Chansha City into the 3 grades of high,middle and low according to the regional economical development situation,2 districts in one grade,including 6 districts.Then each district was redivided into high,middle and low grades according to the economic situation,2 basic medical institutions were selected from each grade.A total of 360 patients were randomly sampled for conducting the questionnaire investigation.The patients and doctors specially participating in the two-way referral conducted the deep interview.Results The patients choosing to primary hospital for first visit accounted for 60.9％.The awareness degree of patients to two-way referral system was 21.1％,and the two-way referral service satisfaction in the patients with two-way referral was 85.7 ％.The patients' will of transfer treatment from primary hospital to superior hospital in case of disease condition need was 82.9 ％.The patients' will for conducting rehabilitation treatment from superior hospital to primary hospital was 77.6 ％.Conclusion Few patients choose primary hospital for first visit.The signing rate of family contract services is low and awareness degree of two-way referral system is not high.

The development and practice of integrated healthcare in China / 中国卫生政策研究

Recently , the country actively explores the pattern of an integrated healthcare which enables the as-sociation among hospitals of different levels , aimed to achieve maximum utilization of medical resources and lead a reasonable distribution of the patients .By reviewing the practices related to the integration of healthcare in Beijing , Shanghai , Zhenjiang and Wuhan city , this paper sums up in five typical mechanisms , i.e.organization and manage-ment mechanism , human resource management mechanism , interest distribution mechanism , service continuity and resources sharing mechanism .The effects of these practices were analyzed and the faced challenges were discussed . The following points were made clear during analysis and discussion:the sustainability of the collaboration mode and organization structure , human resource supports and incentive methods , health insurance guidance for hospitals and patients , two-way referral system and supporting measures , and building of information system .Then we put forward some suggestions , hoping to offer some references to the establishment of integrated healthcare in other regions .

The definition of tiered health care systems and institutional levels from perspective of general practice attributes in China / 中国卫生政策研究

The definition and connotation of tiered health care system ( THCS ) is a fundamental field of re-search for the system and a logic orientation of institution establishment and smoothing as well. Through analyzing and distinguishing the related international and domestic THCS concepts and exploring its essence from the general prac-tice attributes perspective, we found several problems existing in the Chinese THCS. First of all, the three-tiered pa-tient transfer principle which, merely based on the disease, have seriously neglected patient’s health care system serv-ice requirements. Second, the specialty of the general practice lost the function of making a supplement of specialized disciplines. Third, it did not generate a straightforward boundary between the general practice and special care sys-tem. Forth, the organizational management was adopted to replace the professional one required by two specialties. Based on these findings, we gave a clear and smooth THCS definition and answered three fundamental TMSS ques-tions. Additionally, we proposed a concept for which TMSS management should be composed of micro-, medium-and macro-level institutions.

Policy framework and components for general practice-based gatekeeping and referral system / 中国卫生政策研究

Gatekeeping and referral system are core institutional arrangements in health resource allocation which regulate the consumers’ entry points and their fluxion in the healthcare service delivery system. Hiding behind such arrangements are numerous stakeholders and their sophisticated interactions of obligation, responsibility and ben-efits. For this reason, it is of great importance to build a more systematic and integrated policy framework to promote and impoverish the gatekeeping and referral system. This paper puts forward the definition of“general practice-based gatekeeping and referral system” and revealed the political values embedded in it. We then identified the ten essen-tial components for policy implementation based on this definition. For each component, we recognized the involved actors, and elaborated their obligations, boundaries and interactions. This ten-component policy framework could be used in the international comparison research as a map, guiding the implementation of gatekeeping and referral system.

Review of Maternal Deaths at Douala General Hospital, Cameroon: The Referral System and Other Contributing Factors.

One of the objectives of the fifth Millennium Development Goal [MGD] is to decrease annually by 5.5% the maternal mortality so as to attain a three- quarter’s reduction of the world’s burden by the year 2015. The health care referral system has been shown to play an important role if this objective is to be attained. The aim of this study was to evaluate the referral system and other contributing factors to maternal deaths. This was a retrospective, descriptive study carried out in the Douala General Hospital, a tertiary referral hospital in Douala, Cameroon. The records of cases of maternal deaths that occurred between 1st January, 2002 and 31st December, 2011 were reviewed. Patients who died on arrival at the hospital were excluded from the study. Data was collected using pre-structured questionnaire and analyzed with EPI-Info version 3.5.1. There were 25 maternal deaths during this period with a maternal mortality ratio of 275 per 100.000 live births. Sixteen (64%) maternal deaths were referred cases from; government health institutions 4 (25%) and private 12 (75%) hospitals in Douala. Most of the patients were between 30-40 years 12 (48%), married 17 (68%), primigravida 12 (48%). The triad of hemorrhage 12 (48%), hypertensive disease in pregnancy 10 (40%) and infection 3 (12%) was responsible for the maternal deaths. Using two indicators to evaluate the referral system, it was observed that only 3 (18, 8%) exploited the referral information system and barely 4(25 %) were transported to the hospital by an ambulance. Maternal mortality remains high in our setting. Most of the causes of maternal death are due to direct obstetric causes which are preventable. The role of referral system in providing health care is poor. Therefore, this aspect of providing health care has to be properly implemented if it is to make an impact in reducing maternal morbidity and mortality.

Atenção à saúde do idoso: o sistema de referência e contrarreferência nos serviços de saúde / Cuidado de la salud del anciano: el sistema de referencia y contra referencia en servicios de salud / Elderly health care: the referral and counter-referral system in health services

Objective: this study aimed to analyze elderly health care in clinical networks through the referral and counter-referral system, considering the principle of comprehensiveness in the Unified Health System (SUS). Method: constructivist assessment was adopted as a method, responsive, with a hermeneutic dialectic approach, named fourth generation assessment, conducted with 10 nurses who work in the management of health services in a town at the North Zone of the state of Ceará, Brazil, between March and May 2011. Results: the results denote that nurses’ speeches provided information portraying the weaknesses and deficiencies of the referral and counter-referral system at the local levels of health care, with fragmented and disconnected clinical practices. Conclusion: we found out that there is a need to rethink the practice pervading the clinical health care networks, since the elderly person lacks more effective health actions.

Objetivo: o objetivo deste estudo foi analisar a atenção à saúde do idoso nas redes assistenciais por meio do sistema de referência e contrarreferência, considerando o princípio da integralidade no Sistema Único de Saúde (SUS). Método: adotou-se como método a avaliação construtivista, responsiva, com abordagem hermenêutica dialética, denominada avaliação de quarta geração, realizada com 10 enfermeiros que atuam na gestão de serviços de atenção à saúde de um município da Zona Norte do Ceará, entre março e maio de 2011. Resultados: os resultados denotam que os discursos dos enfermeiros proporcionaram informações que retratam as fragilidades e deficiências do sistema de referência e contrarreferência nos níveis locais de saúde, com práticas assistenciais fragmentadas e desconexas. Conclusão: Constatou-se ser necessário repensar a prática que perpassa as redes assistenciais de saúde, uma vez que o idoso carece de ações de saúde mais efetivas.

Objetivo: este estudio tuvo como objetivo analizar la atención de salud del anciano en las redes clínicas a través del sistema de referencia y contra referencia, teniendo en cuenta el principio de la integralidad en el Sistema Único de Salud (SUS). Método: se adoptó la evaluación constructivista como método, responsiva, con abordaje hermenéutico dialéctico, denominado evaluación de cuarta generación, realizada con 10 enfermeros que actúan en la gestión de servicios de atención de salud en un municipio en la Zona Norte del estado de Ceará, Brasil, entre marzo y mayo de 2011. Resultados: los resultados denotan que los discursos de los enfermeros proporcionaron informaciones que retratan las fragilidades y deficiencias del sistema de referencia y contra referencia en los niveles locales de salud, con prácticas clínicas fragmentadas e inconexas. Conclusión: se constató que hay una necesidad de repensar la práctica que impregna las redes clínicas de salud, ya que el anciano carece de acciones de salud más efectivas.

Clinical Analysis of Characteristics of Patients Who Visit Otorhinolaryngology Clinic in Secondary General Hospital / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Common cold is an upper airway viral infection and can be managed by conservative treatment. According to the hospital referral system, mild diseases like common cold should be treated first at a primary physician clinic. However, now in Korea, visiting high-level hospitals for mild diseases is not impossible officially and even the rate of visiting high-level general hospital has increased in spite of the current hospital referral system. This study aimed to provide data of characteristics of patients who choose high-level hospitals for mild diseases like common cold. SUBJECTS AND METHOD: We conducted a survey targeting those who visit general hospitals for common cold. The questionnaire comprised of asking first choice of contact hospital, sex, age, awareness and use of antibiotics when visiting primary physician, medical examinations and duration of treatment, and reasons for thinking that general hospitals are superior to primary hospitals. Subjects were categorized according to their choice of first contact hospital with common cold, primary physician or general hospital. For each group, independent sample t-test and chi-square test were applied to variables. RESULTS: Among the variables for the two groups, statistical significances were found in age, duration of treatment and whether medical examinations were performed or not. CONCLUSION: Underestimation for primary physician and vague faith in medical examinations were most influential factors that lead patients with mild diseases to visit general hospitals. This study finds that programs for educating the public are necessary to make them understand that primary physician clinics are enough to treat common cold and that an institutional framework will be needed to support the hospital referral system.

Change of patients' health service seeking patterns by community health service institutions / 中华医院管理杂志

Objective To explore effective ways for community health service institutions to change patients' health service seeking patterns. Methods Yuetan Community Health Service Center of Fuxing Hospital affiliated to Capital Medical University and 9 community health service stations under its subordination in the 1996～2002 period were selected as a representative of the community health service institutions to be studied and intervened while the headquarters of Fuxing Hospital in the same period was selected as a representative of the third-tier hospitals to be studied. A comparison was made between the two in outpatient volume change. Questionnaires were distributed randomly to residents of the Yuetan area where Fuxing Hospital is located in order to study their health service seeking behaviors each year from 1996 to 2002. Results As a result of hard work in the 6 years, Yuetan Community Health Service Center saw a steady increase in outpatient volume whereas the headquarters of Fuxing Hospital witnessed a steady decrease in outpatient volume. Survey via questionnaires sent randomly to permanent residents of the Yuetan area indicated a change in residents' health service seeking patterns. Conclusion It is effective and viable for community health service institutions to change patients' health service seeking patterns through providing social-psychological-biological community medical services, enhancing health education and setting up a two-way referral system with third-tier hospitals.

Impacts of Implementation of Patient Referral System in terms of Medical Expenditures and Medical Utilization / 예방의학회지

A new medical delivery system which regulated outpatient department(OPD) use from tertiary care hospitals was adopted in 1989. Under the new system, patients using tertiary care hospital OPD without referral slip from clinics or hospital could not get any insuranced benefit for the services received from the tertiary care hospital. This study was conducted to evaluate the Patient Referral System(PRS) with respect to health care expenditures and utilization. Two data sets were used in this study. One was monthly data set(from January 1986 to December 1992)from the Annual Report of Korea Medical Insurance Corporation(KMIC). The other was monthly joint data set composed of personal data of which 10% were selected randomly with their utilization data of KMIC from January 1988 to December 1992. The data were analyzed by time-series intervention model of SAS-ETS. The results of this study were as follows: 1. There was no statistically significant changes in per capita expenditures following PRS. 2. Utilization episodes per capita was increased statistically significantly after implementation of PRS. The use of clinics and hospitals increased significantly, whereas in tertiary care hospitals the use decreased significantly immediately after implementation of PRS and increased afterwards. 3. Follow-up visits per episode were decreased statistically significantly after implementation of PRS. The decrease of follow-up visits per episode were remarkable in clinics and hospitals, whereas in tertiary care hospitals it was increased significantly after implementation of PRS. 4. There was no statistically significant changes in prescribing days per episode following PRS. Futhermore, clinics and hospitals showed a statistically significant decrease in prescribing days per episode, whereas in tertiary care hospital it shower statistically significant increase after implementation of PRS. 5. Except high income class, the use of tertiary care hospitals showed statistically significant decrease after implementation of PRS. The degree of decrease in the use of tertiary card hospitals was inversely proportional to income. These results suggest that the PRS policy was not efficient because per capita expenditures did not decrease, and was not effective because utilization episodes per capita, follow-up visits per episode, and prescribing days per episode were not predictable and failed to show proper utilization. It was somewhat positive that utilization episodes per capita were decreased temporarily in tertiary card hospitals. And PRS policy was not appropriate because utilization episodes per capita was different among income groups. In conclusion, the PRS should be revised for initial goal attainment of cost containment and proper health care utilization.

A Comparative Study on the Pattern of Outpatient Department Utilization at a Tertiary Level Hospital before and after Implementation of the Patient Referral System / 예방의학회지

This study was conducted to assess the effects of implementation of the patient referral system started July 1st, 1989. A comparison on the pattern of outpatient services of the Departments of Internal Medicine, General Surgery, and Pediatrics at the Yeungnam University Hospital was conducted for each one year period before and after implementation of the patient referral system. The pre-implementation period was from July 1. 1988 to June 30, 1989 and the post-implementation period was from July 1. 1989 to June 30, 1990. The information used for this study was obtained from official forms, prepared by the Yeungnam University Hospital, and submitted to the Korean Medical Insurance Cooperatives. After implementation of the patient referral system, the number of outpatient cases in the Department of Internal Medicine decreased 36.1% from 9,669 cases to 6,181 cases a year. Cases in the Department of General Surgery decreased 23.7% from 1,864 cases to 1,422 cases a year. The number of cases in the Department of General Surgery decreased 23.7% from 1,864 cases to 1,422 cases a year. The number of cases in the Department of Pediatrics decreased 36.9% from 3,372 cases to 2,128 cases a year. After implementation of the patient referral system, the average age of cases in the Departments of Internal Medicine and General Surgery was 52.5 and 49.7 years old, respcetively. This was a significant increase in comparison with the pre-implementation period. After implementation of patient referral system, the proportion of new outpatients in the Department of Internal Medicine decreased form 24.1% to 14.6%, the Department of General Surgery from 36.0% to 23.4%, and the Department of Pediatrics from 15.5% to 8.3%. The number of visits per case decreased significantly in the Department of Internal Medicine(from 1.74 to 1.61), but there was no significant change in the Department of General Surgery and Pediatrics. The length of treatment per case increased significantly in all three departments (form 16.1 days to 19.3 days in the Department of Internal Medicine, from 12.0 days to 15.2 days in the Department General Surgery, and 8.9 days to 11.2 days in the Department of Pediatrics). The number of clinical tests per case increased significantly in the Department of Internal Medicine (from 22. to 2.5), in the Department of Pediatrics(from 0.8 to 1.1) and increased in the Department of General Surgery(from 6.4 to 6.6). The average medical cost per case decreased form 43,900 Won to 42,500 Won in the Department of Internal Medicine, while the cost increased from 75,900 Won to 78,500 Won in the Department of General Surgery and from 12,700 Won to 13,500 Won in the Department of Pediatrics. In case-mix, the chronic degenerative disease(i. e. hypertension, diabetes mellitus, angina pectoris, malignant neoplasm, and pulmonary tuberculosis) ranked higher and acute infectious diseases and simple cases(i. e. gastritis and duodenitis, haemorrhoids, anal fissure, carbuncle, acute URI, and bronchitis) ranked lower after implementation of the patient referral system compared to before implementation.

An Evaluative Analysis of the Referral System for Insurance Patients / 예방의학회지

This study examined the effects of referral requirements for insurance patients which have been enforced since July 1, 1989 when medical insurance coverage was extended to the whole population except beneficiaries of medical assistance program. The requirements are mainly aimed at discourag - ing the use of to Vii; ry care hospitals by imposing restrictions on the patient's choice of a medical service facility. The expectation is that such change in the pattern of medical care utilization would produce several desirable effects including increased efficiency in patient care and balanced development of various types of medical service facilities. In this study, these effects were assessed by the change in the number of out-patient visits and bed-days per illness episode and the share of each type of facility in the volume of services and the amount of expenditures after the implementation of the new referral system. The data for analysis were obtained from the claims to the insurance for government and school employees. The sample was drawn from the claims for the patients treated during the first six months of 1989, prior to the enforcement of referral requirements, and those of the patients treated during the first six months of 1990, after the enforcement. The 1989 sample included 299,824 claims (3.6% of total) and the 1990 sample included 332,131(3.7% of total). The data were processed to make the unit of analysis an illness episode instead of an insurance claim. The facilities and types of care utilized for a given illness episode are defined to make up the pathway of medical care uti lization. This pathway was conceived of as a Markov Chain process for further analysis. The conclusion emerged from the analysis is that the enforcement of referral requirements resulted in less use of tertiary care hospitals, and thereby decreased the volume of services and the amount of insurance expenses per illness episode. However, there are a few points that have to be taken into account in relation to the conclusion. The new referral system is likely to increase the use of medical services not covered by insurance, so that its impact on national health expenditures would be different from. that on insurance expenditures. The extension of insurance coverage must have inereased patient load for all types of medical service organizations, and this increase may be partly responsible for producing the effects attributed to the new referral system. For example, excessive patient load for tertiary care hospitals may lead to the transfer of their patients to other types of facilities. Another point is that the data for this study correspond to very early phase of the new system. But both patients and medical care providers would adapt themselves to the new system to avoid or overcome its disadvantages for them, so as that its effects could change over time. Therefore, it is still necessary to closely monitor the impact of the referral requirements.