New experience of implementing patient e-referral in the Iranian health system: a qualitative study

Abstract

Background

Implementing an electronic system of service categorization and a referral system in healthcare is a strategic approach to improving overall health outcomes and optimizing resource use. This study aimed to investigate challenges experienced with the electronic patient referral system in Mashhad University of Medical Sciences (MUMS).

Methods

In this qualitative research, data were collected using semi-structured interviews. Participants included physicians, experts, and stakeholders working in the Family Physician Program and the referral system, selected through purposive sampling. The data were analyzed using a thematic analysis framework, in which a thematic framework was developed, and key themes were identified. Data analysis was performed using Atlas.ti8 software.

Results

According to the interviewees, the challenges of digitizing the referral system can be categorized into three main themes: structure, process, and outcomes. These themes include ten sub-themes, such as challenges related to Internet Infrastructure and the Sina System, Patients’ Choice of Desired Specialists, Receiving Payment for Services, Appointment Scheduling, Interdepartmental Coordination, Recording Definitive Diagnosis Codes Before Referral, False Referrals, Dissatisfaction, Feedbacks, and Health Indicators.

Conclusion

To improve the e-referral in Iran’s health system, several strategies can be implemented. These include sustainable resource allocation, designing consequence mechanisms within the referral system to motivate collaboration and improving appointment scheduling systems. Furthermore, addressing these challenges requires a collaborative approach involving healthcare providers, IT professionals, and patient representatives to ensure that the system is efficient, user-friendly, and effectively meets the needs of all parties involved. Not paying enough attention to these issues cause reform failure while solving them requires multi-dimensional, systematic and coordinated interventions with a deep understanding of the obstacles and challenges. Disregarding these factors may result in apathy over time, ultimately impacting both the quantity and, more importantly, the quality of services.

Background

The healthcare system aims to achieve greater efficiency, effectiveness, and equity in providing healthcare services, ensuring access for the general population to organized levels of care categorized as primary, secondary, and tertiary. Depending on the service categorization, access to specialized services is made possible through a referral system, allowing individuals in need to access more specialized care [1]. The referral system is an international experience that has demonstrated significant effectiveness in prevention, treatment, and resource control. In many countries, including North America, Western Europe, and Canada, family physicians are responsible for delivering health services and leading health teams. In countries such as Britain, Canada, South Korea, and Chile, the national healthcare system is based on the referral system and family physicians [2].

The implementation of the referral system is one of the most strategic programs for healthcare systems globally, with potential outcomes including quality enhancement through standardized care and treatment guidelines, improved access to limited resources and cost control, prevention of induced demand by reducing unnecessary patient visits to hospitals and emergency departments, prevention of multiple referrals to different medical centers, and meeting a significant portion of health needs at the primary service level, leading to increased satisfaction [3,4,5,6].

In recent years, the healthcare landscape in Iran has undergone significant transformations aimed at enhancing the accessibility, efficiency, and quality of medical services. One of the most notable advancements in this realm is the implementation of an e-referral, a crucial component of the country’s health information technology initiatives. The goal of the e-referral is to streamline patient care by facilitating seamless communication between different levels of healthcare providers, ranging from primary care to specialized medical services. This system not only aims to improve the referral process but also seeks to reduce patient wait times, minimize unnecessary examinations, and optimize resource allocation within the healthcare system. As Iran grapples with the complexities of a growing population and an evolving healthcare framework, the e-referral stands as a pivotal innovation designed to ensure that patients receive timely and appropriate care while enhancing the overall efficacy of the health system [7, 8].

In order to address the barriers hindering the effective implementation of the patient referral system in the region covered by MUMS, an electronic patient referral system has been in operation within the Sina electronic system and Hospital Information System (HIS) since September 2018. Mums is one of Iran leading medical universities, situated in Mashhad, the second most populous city in Iran with a population of 3,131,586, and serving as the capital of Razavi Khorasan province. Mums is responsible for healthcare, treatment, and medical education in the region. This article delves into the challenges of the e-referral from the providers’ perspective, illustrating its potential to revolutionize patient management and improve health outcomes across the nation.

Methods

This qualitative study was conducted using a thematic analysis approach in the year 2020. The research population consisted of managers, physicians, referral liaison experts, and system users chosen through purposeful sampling. Referral liaison experts and managers are professionals who oversee and coordinate the process of referring patients from one healthcare provider to another within the system. Their primary role is to ensure that patients receive appropriate care through timely and accurate referrals. The initial participants were selected based on the recommendation of the administrative committee, individuals with a better understanding of the health team members. Other participants were identified through consultation and discussion with each participant.

Initial interviews were conducted in-depth and with a simple predefined structure based on the study reviews and research experience, gradually developed to semi-structured interviews. Ultimately, the interview guide consists of 12 interview questions. Interviews were recorded on mobile devices after obtaining participants’ permission and then transcribed onto paper. At the end of each session, the notes were reviewed, and key points were corrected or modified. Data collection continued until saturation was reached, meaning when new information was no longer being provided by participants and redundant information was observed. In total, interviews were conducted with 11 physicians, 4 family physician program expansion managers, 3 referral liaisons, and 3 reception personnel. Each interview lasted between 45 and 60 min.

The interview used was developed for this study and the Interview guide presented in appendix1. Inclusion criteria were willingness to participate in the study, having a minimum of 2 years of experience in the rural family physician program in Khorasan Razavi province for physicians, holding a relevant management position in the family physician program for managers, and being designated by the health and medical network manager as the referral liaison for experts.

To ensure the accuracy and reliability of the data, Lincoln and Guba’s criteria for trustworthiness were used, including credibility, dependability, transferability, and confirmability [9]. Data accuracy was validated through participant review for data and codes (credibility). To ensure the reliability of the data, initial codes, examples of extracting subcategories within themes, and selected interview excerpts for each subcategory were shared with an external auditor familiar with qualitative research analysis to confirm consistency or divergence in their understanding compared to the researcher (dependability). To establish confirmability, the multiple interview transcripts, codes, and extracted subcategories were shared with colleagues who were familiar with qualitative research methods but were not part of this study, and they were asked to assess the accuracy of the data coding process.

This study was compared with other relevant studies to assess consistency in findings, indicating transferability. Verbal consent was obtained from participants, and interviews were recorded only after obtaining permission. Participants’ information remained confidential, and they had the right to withdraw from the study at any stage. This study was approved by the ethics committee of the Mashhad University of Medical Sciences.

For data analysis, a qualitative framework analysis method consisting of five stages, namely “Familiarization, identifying a thematic framework, Indexing, Charting, and Mapping and interpretation,” was employed [10]. The text of each interview was transcribed onto paper within less than 24 h. In this analytical approach, the research team first identified key concepts and topics based on their understanding of the domain and content diversity. They then established a thematic framework according to these identified concepts. Subsequently, all transcripts from individual interviews were reviewed and annotated based on the established thematic framework. An appropriate thematic source was used for arrangement. Concepts, contradictions, theories, experiences, and previous research were compared, and patterns and relationships were deduced from the findings. Simultaneously with data collection, the coding process began. Primary concepts were defined through initial codes. In the subsequent stage, codes with similar meanings were grouped together, forming subcategories. The software Atlas.ti8 was utilized for data management.

Research ethics

All participants received detailed information about the study, that participation was voluntary and that they could withdraw from the study without obligation or giving notice after giving this information, verbal informed consent was obtained from each individual before being interviewed which is approved by Ethics Committee of Mashhad University of Medical Sciences. )IR.MUMS.REC.1399.441 (. All data were kept confidential and viewed only by the research team. All study methods were carried out in accordance with relevant guidelines and regulations.

Results

In this research, 21 individuals, comprising of 13 women and 8 men, aged between 23 and 45, participated. Within this group of individuals, 52% had earned doctoral degrees, 10% had obtained master’s degrees, 28% had completed bachelor’s degrees, and 10% had received high school diplomas. According to the interviewees, challenges related to the electronic transformation of the referral system at Mashhad University of Medical Sciences were categorized into three main themes: Structure, Process, and Outcome. These encompassed ten sub-themes: Challenges in the Internet Infrastructure and Sina System, Patients’ Choice of Desired Specialists, Receiving Payment for Services, Appointment Scheduling, Interdepartmental Coordination, Recording Definitive Diagnosis Codes Before Referral, False Referrals, Dissatisfaction, Feedbacks, Health Indicators. The e-referral challenges, including main topics, subtopics and sub-subtopics are presented in Table 1.

Table 1 E-referral challenges in Mashhad University of Medical Sciences

Internet infrastructure and Sina system

Since the month of Mehr in the year 1395 (September 2016), Mashhad University of Medical Sciences, in line with other medical universities across the country, has embarked on providing healthcare services electronically and has introduced the electronic system called “Sina.” Given that speed in registering services provided to patients is a fundamental priority in this field, having up-to-date infrastructure and servers, as well as ensuring stable and suitable internet access throughout the country, especially in rural areas, is essential. The inability to provide services to patients during internet outages, the possibility of disputes and conflicts at healthcare centers, paper-based referrals, and the inability to record provided services in the system due to slow internet speed, weak e-government infrastructure, and offline status of some villages and health centers are among the issues addressed in connection with this topic. A physician expressed “The Sina system has improved a lot in terms of speed. Previously, we had frequent power, internet, and system outages, but now it’s been a week or ten days without any interruptions.” Another physician stated, “Regarding the Sina system and internet, well, if I want to mention their problems, we have a lot of internet outages throughout the month. When the system goes down, the patient has to wait a lot until it’s reconnected. Sometimes it takes hours, and the patient with pain is in trouble. They have to wait a long time, and nobody takes responsibility. They simply tell them to come back another day when the system is working. Sometimes disputes arise, and conflicts occur.” (P1). A referral liaison expert mentioned, “The problem that exists is that out of the four health centers under my coverage, one of them doesn’t have internet and is completely offline. The other three have extremely slow internet speed, and it’s impossible for you to open a form for one person and refer them. It takes around 15 minutes for you, during which you have to keep all the people waiting, and in those 15 minutes, you can only refer one person.” (P4).

Receiving payment for services

Based on data analysis and concept extraction, the impossibility of accepting and issuing receipts in the absence of a bank card, the illegal collection of cash from patients, the inability of the elderly to use bank cards, and the inability to refund money to patients in case of appointment cancellations are among the issues mentioned in this context. A reception staff mentioned, “Regarding bank cards and cash, especially in rural areas, people are not familiar with using cards, and they don’t know the PIN password. They mostly give cash. Another thing is that we have to take the patient’s card, open their online account, view all the information and bank card details, and also take the patient’s card PIN to be able to schedule an appointment for them. This is not interesting in itself, as personal banking information should not be in our possession. Some people really objected and were dissatisfied that their banking information was in our possession. But generally, most people trust us. As for the cash we collect from patients, we are obliged to withdraw that cash from our own personal card.” (P3). Another physician declared “Then there’s the issue of bank cards. Unfortunately, there are some people, especially the elderly, who neither have bank cards nor know how to use them. This will cause numerous problems for patient acceptance in healthcare centers and, of course, for the referral system. It will undoubtedly create problems.” (P8). In this regard, an expansion managers stated, “Well, certainly many of the patients refuse to give their bank card PIN to the reception, and on the other hand, there are health-related problems with receiving cash. When cash is collected, there are problems related to depositing the money, and the cash needs to be deposited into the designated accounts. Therefore, when cash is collected, it has to be deposited into the accounts that have been determined. The issue of paying and receiving cash also has some prohibitions, which are determined by the relevant financial units.” (P2).

Appointment scheduling

According to the participants in this research, the issues related to appointment scheduling include the slowness of the appointment system, limited daily appointments, irregular presence of specialists, the inability to schedule appointments in rural areas, the delayed loading of specialists’ availability schedules, long waiting times for appointment dates, the reluctance of rural residents to take afternoon appointments, non-specialized reception staff, and their inability to effectively schedule appointments. A referral liaison stated “Sometimes a patient needs an appointment with a specialist for today, but since there are no available slots for today, they are told to schedule for tomorrow or the day after tomorrow. In such cases, the patient won’t wait and might go to private clinics or personal offices like Imam Khomeini clinic.” (P4).

“Another issue is that the available appointment slots for specialists in the system are very limited and scarce. Interestingly, they keep telling us to refer patients, but when we refer them, they reach the reception and find out that there are no available slots.” “We don’t have many specialists in the county.” “Many times, due to the absence of all specialists in the county, we refer patients to other specialists. Patients who can afford it go to private clinics or go to Mashhad without waiting. However, those who cannot afford it or don’t have the money are forced to visit the specialists we refer them to, which are usually closely related specialties where patients can be referred internally if necessary. For example, internal medicine with cardiology, orthopedics with neurology.” (P5).

Recording definitive diagnosis codes before referral

Recording a definitive diagnosis code before making a referral has implications for the acceleration of patient diagnosis, treatment processes, and recovery. The inability to make an accurate diagnosis at the primary care level becomes a reason for referring patients to specialized levels. As a result, family doctors provide a probable diagnosis and then refer the patient. The mandatory registration of a definitive diagnosis code before making a referral has led to dissatisfaction among family doctors. One physician explains, “Another issue we have is that during referrals, they say you must enter a definitive diagnosis for the patient before making the referral. for example, a patient comes to me and says they have knee pain. In the referral form, there are several items in the definitive diagnosis section. In this case, I should enter ‘knee osteoarthritis’ as a definitive diagnosis and then make the referral. You see, if I knew the diagnosis and I was sure that this was their problem, I would treat it myself. Why do I need to refer them? Later, I see that in the system, they’ve added a general definitive diagnosis, and after they see a specialist, they find out they didn’t have that problem.” (P3) Another interviewee highlights, “If I know the diagnosis and want to enter a definitive diagnosis for someone, why should I send them to a specialist? There are two scenarios. Either I’m not really sure about the diagnosis, and I think to myself, why should I enter this code as definitive so that I can refer them? Maybe a problem arises, or it might be a code that I can’t remove later, like with non-referrable patients, and I can’t delete the code until the end of the patient’s record. This is a problem in this part.” (P6).

False referrals

Issues related to false referrals include requesting referrals without the doctor’s opinion, sending documents for endorsement without the patient’s presence, network specialists advising to increase patient referrals by more than 15%, the significant impact of referral and appointment percentage on doctors’ scores and earnings, patients’ lack of trust in family doctors, specialists’ dissatisfaction with unprofessional referrals and their reluctance to register non-appointment referrals, creating false referrals to gain monitoring score points, visiting doctors with others’ referral documents, recording incorrect diagnoses and problems in subsequent care, the absence of a private section in the appointment system, the time-consuming process of electronic referrals, unnecessary referrals, increased workload for specialists, and their increased dissatisfaction. One physician states, “You can see in the referral system that when a patient comes to me, I try to solve their problem myself as much as I can. The patient asks for a specialist referral or asks us to do it in the system. I always ask what the problem is. We have a lot of problems like back pain, leg pain, and orthopedic issues. But the network strongly opposes this and asks why I’m doing this. There was a time when a lower percentage of referrals to specialists was better, but now it’s the opposite. They say to refer as much as you can.” (P15) “We have a percentage of referrals in the PFQ score, and it has a lot of points.” (P8) “You see, we can manage and treat many patients ourselves, but due to the network’s pressure to increase the referral percentage, and since patients have gotten used to it and unfortunately don’t trust general practitioners anymore, we are forced to refer patients. This is unprofessional.” (P3) “Another issue is the misuse of rural referral forms. Many patients use other people’s rural referral forms (relatives, neighbors, etc.). There have been reported cases, but the family physicians and supervisory authorities don’t pay much attention to this issue. They overlook it, and this leads doctors to issue white referral forms.” (P9) In the context of appointment scheduling, there are issues such as the inability to get appointments for the desired specialists, patients’ dissatisfaction with long delays in health centers, and the high number of visitors. Patients are also dissatisfied with the mandatory payment through bank cards. “If a specialist is not present in the health center, regardless of the appointments made, there is no communication with individuals to cancel or report the specialist’s absence. This can lead to dissatisfaction and a lack of trust in this system.” (P2).

Dissatisfaction

Doctors and users express dissatisfaction due to poor internet connectivity, frequent disconnections, and slow system speed, which pose significant challenges. An expansion manager explained, “The appointment scheduling section often fails due to the slow system and slow internet speed. Patients have to wait, and it may lead to conflicts and disputes, or they leave and come back later. But sometimes, when they return, it’s at the end of the day, and many times they don’t come back at all, and the doctor complains why the patient wasn’t scheduled in the initial time.” (P1) Physicians raise concerns about the pressure to maintain a high referral percentage, which is tied to their scores and income. Some colleagues feel compelled to make unnecessary referrals just to increase their referral percentage to meet this requirement, which leads to dissatisfaction among doctors. “One of the biggest problems I encountered is that they say your referral percentage should be above 15%, but mine is currently below 5%. A portion of our monitoring score is tied to this percentage, and this difference can amount to a significant sum of money. Sometimes colleagues are forced to make false referrals just to get points for their PFQ score and increase their referral percentage. This is unnecessary, and it’s a waste of time.” (P6). “Another issue is the substantial number of rural residents who have migrated to the outskirts of Mashhad but still possess rural health insurance booklets. These individuals often send their booklets back to their rural hometowns for stamping due to the high costs of healthcare in the city. Despite residing outside the coverage area, they expect their booklets to be stamped, creating a significant challenge that has caused numerous complications.”

Feedbacks

Regarding feedback, a family physician stated, “Specialists rarely provide feedback because they’re in the treatment sector, and they don’t receive any scores or incentives for giving feedback. I don’t think they even have a system to record patient feedback. I’ve never seen a specialist provide feedback. It’s because they are in the treatment department, not the health department, and they don’t receive any scores or incentives for it. Maybe it’s due to their limited time as well, as specialists are often busy and might not have time to provide feedback” (P 1). “Feedback from specialists doesn’t offer us much. It’s just a formality and we don’t really make use of it. Even the diagnoses they provide are often limited to these diagnostic codes that they can’t use extensively. Sometimes they only write ‘revisit’ in follow-ups without giving us any guidance on what to do with the patient. From then on, we are forced to ask the patients themselves what they said. Considering that patients often lack the knowledge and information to provide accurate information, this leads us to face subsequent challenges where we have to make educated guesses on what to do next” (P 9). An expert in the field mentions, “The number of feedback instances isn’t proportional to the number of referrals. We don’t know where the problem lies, whether the person didn’t actually visit the hospital or if the patient did visit but the hospital didn’t provide feedback. We don’t have any information at level one unless we call, and this is time-consuming. If there could be a list of individuals referred to level two in the system, we could see who has visited level two. This way, we could understand the effectiveness of our referrals and whether the patient actually visited” (P 3).

Health indicators

Health indicators show the progress of the program and the extent to which goals are being met. Monitoring these indicators can be useful for physicians and support the improvement of targeted programs. However, challenges in this area include the inability for general practitioners to access and observe health indicators within the SINA system. Some physicians resort to manually counting visits for statistical purposes. A physician expresses, “The challenge lies in the impossibility of general practitioners accessing and observing health indicators. We don’t have the means to see the percentage of referral compliance or any other relevant information. It’s better if we had access to electronic indicators for referrals, appointment scheduling, and more” (P 9).

Discussion

The present study was qualitative research aimed at identifying the challenges of the e-referral in the Family Physician Program based on providers’ perspective. The challenges of internet as an infrastructure present significant barrier to the effective functioning of the e-referral in the Iranian health system. One major issue is the limited access to high-speed internet in certain regions of the country, which can result in slow connection speeds and interrupted service which can lead to delays in the referral process, affecting the overall efficiency of the program. Additionally, the unstable nature of the internet connection in Iran can also lead to data loss or corruption, further complicating the referral process. Moreover, the lack of reliable internet infrastructure can hinder communication between healthcare providers, patients, and administrators, making it difficult to coordinate care and exchange important medical information efficiently. This can lead to misunderstandings, errors, and delays in patient treatment, ultimately impacting the quality of healthcare delivery in the program. Addressing these issues will be crucial in ensuring the success and sustainability of the program, as it will allow for prompt case management and enhance the existing chaotic referral procedure. Health workers will be helped by the adoption of an e-referral system, A collaborative platform that allows for easy searching and discovery of healthcare providers can aid in decision-making and simplify the process for more efficient patient care [11].

Challenges regarding patient choice in select a specialist for their medical needs along with delayed appointment scheduling and long waiting times, are major issues that have been reported in studies by Nakhaii, Hamrahi, Nasiri Pour, Naseriasl and their colleagues [12,13,14,15]. This aspect of the system can be complex as it involves coordinating the availability of multiple parties - referring physicians, specialists, and patients. It is essential to ensure that appointments are scheduled in a timely and efficient manner to avoid delays in patient care. By implementing clear protocols, integrating with scheduling software, and providing adequate training and support, healthcare organizations can improve the coordination of appointments and ultimately enhance patient care and satisfaction [13, 16, 17]. However, Haper’s study on “Reducing Waiting Time for Walk-in Patients” concluded that establishing proper scheduling programs can significantly reduce patient waiting times without the need for additional resources [18].

Interdepartmental coordination is a crucial aspect of implementing an e-referral in any organization, including in Iran. The lack of coordination between different departments can lead to inefficiencies, delays, and even failures in the execution of the program. The study revealed a significant gap in inter-departmental coordination, which hindered the proper functioning of the system. Another significant problem uncovered is the lack of proper functionality within the insurance organization. This can result in a myriad of issues such as conflicting patient identity information among different departments, slow updates of patient information, and a lack of sensitivity from insurance organizations towards validity dates. These issues can lead to confusion, errors, and delays in providing important services to patients which is align with other studies [19,20,21]. Therefore, a concerted effort would be needed from all stakeholders involved to enhance the functionality of the program [22, 23].

Consistent with other studies false referral-related problems can have various negative consequences within the healthcare system. One common issue is when individuals request referral stamps without a physician’s opinion. This can lead to inappropriate referrals and potentially harm patient care. Additionally, reversed referrals, where patients are sent to the wrong specialist, can result in delays in receiving proper treatment and negatively impact patient outcomes. Furthermore, unprofessional referrals can lead to breakdowns in communication between healthcare providers, which may further compromise patient care. Also, some individuals may make false referrals to gain points or benefits within a healthcare system, which not only undermines the integrity of the referral process but also wastes valuable resources [4, 13, 24, 25]. It is important for all providers involved in the referral process to adhere to ethical practices, communicate effectively, and prioritize patient-centered care.

The challenges faced by e-referral often stem from several interconnected factors: physician and patient dissatisfaction, feedback mechanisms, and health indicators which is consistent with other studies [13, 17, 26, 27]. Complex or non-intuitive systems can cause frustration among physicians who are already constrained for time. Additional, if the interface is not user-friendly, it can lead to significant dissatisfaction. Inadequate training on using e-referral systems, workflow disruption, and delayed response time can leave both physicians and patients feeling unsupported. Continuous technical support and training are essential to address issues promptly [7, 11, 23].

Role of Feedback and health indicator are among the other challenges mentioned in this study while empirical studies suggest that health services can use positive feedback to create patient benefit [25, 28, 29]. Sherwani and colleagues’ study showed that only 16.85% of patients referred to level two were accepted by specialist physicians, and the outcomes were then communicated back to their family physician. Of those patients referred to level two, only 15.5% returned to their referring physician. Furthermore, 85.3% of patients who did not return to level one cited lack of awareness as the main reason [30]. Effective feedback mechanisms are crucial for the success of e-referral systems. Physicians need to receive timely updates and outcomes from specialists to ensure continuity of care. Therefore, feedback loops, system improvement and patient feedback are essential components for the success of e-referral systems. It is important that user suggestions can pinpoint areas needing enhancement.

Finally, e-referral systems must maintain high standards of accuracy in patient health indicators to ensure proper diagnosis and treatment plans. Inaccuracies can lead to inappropriate referrals and treatments. This health indicators need to be thoroughly integrated across various health information systems to ensure that all relevant data is available for making informed referral decisions. So, tracking outcomes and monitoring health outcomes and post-referral can help in assessing the efficiency and effectiveness of the e-referral system. Addressing these challenges requires a collaborative approach involving healthcare providers, IT professionals, and patient representatives to ensure that the system is efficient, user-friendly, and effectively meets the needs of all parties involved [8, 23, 29].

Conclusion

Despite the steps taken to strengthen the categorized system of health service delivery in the country, it contains serious defects in the evolution and institutionalization of the electronic referral system as a basic platform for other national health plan such as Family Physician Program. Serious flaws in structure, appointment booking, wait times, visits, diagnosis, feedback, interdepartmental inconsistencies in the Iranian e-referral lead to improper functioning in the healthcare system and dissatisfaction among providers. To improve this situation several strategies can be implemented. These include sustainable resource allocation, designing consequence mechanisms within the referral system to motivate collaboration and improving appointment scheduling systems. Furthermore, addressing these challenges requires a collaborative approach involving healthcare providers, IT professionals, and patient representatives to ensure that the system is efficient, user-friendly, and effectively meets the needs of all parties involved. Not paying enough attention to these issues cause reform failure while solving them requires multi-dimensional, systematic and coordinated interventions with a deep understanding of the obstacles and challenges. Disregarding these factors may result in apathy over time, ultimately impacting both the quantity and, more importantly, the quality of services.