Abstract: Background: The public sector of the health care system provides justice and access for all people who need more specialized services through the referral system. If the challenges of the referral system are not identified and addressed promptly, the system will not be efficient and effective. The purpose of this study was to rank the reasons for non-referral of outpatient level 1 to level 2 in the electronic referral system of Golestan province in 2019. Methods: In this descriptive and cross-sectional study, 431 outpatients participated from the pilot hospitals of the e-referral system in Golestan province, who did not refer to the level 2 specialist despite that an appointment was set by the system. The participants were selected using a stratified random sampling method. Data were collected using a questionnaire and analyzed by descriptive statistics and Friedman test in SPSS 23 software. Results: The most important reasons for patients who were not  referred from level 1 to level 2 in the electronic referral system included the presence of a trusted and familiar physician, inability to pay the visit of a specialist, and high cost of transportation from home to the designated specialist, respectively. The gender of the specialist physician and lack of guidance on referral to the specialist physician were indicated by the referral center. Patients ranked the reasons of not referring to the specialist differently (P 〈 0.001). Conclusions: The current status can be improved by increasing the public confidence in specialized physicians working in the electronic referral system and making the specialized services free for the poor patients. Furthermore, raising the patient's awareness about using Level 2 specialized services through the mass media can help patients to benefit from these services.

Abstract: The electronic referral system faces management, administrative, educational, policy, sociocultural, technological, and economic challenges. Managerial challenges are divided into four categories: planning, organisation, motivation, and control. Executive challenges are divided into four categories: scheduling, patient load and waiting time, visit and diagnosis, and feedback. Educational challenges are divided into two categories: health care system and society.

Abstract: Background and objectives Health system services are not reliable without quality assessment. It is important to explore gaps between standard services and existing situation to improve the quality of health system. His study aimed at studding the quality assessment of electronic referral system in one of the major provinces of Iran. Material and Methods This study was a cross-sectional study utilizing SERVQUAL model. The population comprised 3 groups totaling approximately 11,004 people. The sample size allocated to each city was determined in view of the ratio of patients. A sample of 384 patients who used electronic referral service at level 2 and revived outpatient services constructed the population of study. The data were collected through a two-part questionnaire. The validity of the questionnaire was confirmed by 10 experts including senior and mid-level managers and medical science university faculty members. The questionnaire assessed demographic data and the patients' perceptions and expectations. Data was analyzed using descriptive statistics and analytical statistics such as nonparametric mean comparison tests, in view of the normality assumption,) including Wilcoxon test, Mann-Whitney and Kruskal-Wallis. Spearman correlation test was used to determine the intensity of correlation between the study variables. The significance level of all tests was considered 0.05. Results There were identified gaps throughout all dimensions of health service among the studied clinics (P 〈 0.001). The highest gap was observed in the empathy dimension (0.57) and the lowest gap was observed in the tangible dimension (-0.38). The gap between the services provided to patients was different in terms of guarantee, gender (P = 0.005), empathy , level of education (P = 0.028) and reliability based on the city vise (P = 0.028). Conclusion In the hospitals implementing the electronic referral system in Golestan province, there is a gap in all dimensions and it indicates that in none of the dimensions, the expectations of the recipients have not been fully met. Extended Abstract Background and Objectives Quality assessment is doubly important in the health sector, compared to other sectors, due to the sensitivity of services provided in this area. This study was conducted to investigate the gap in the quality of medical services provided in hospitals implementing electronic referral system in Golestan province, using SERVQUAL model. Material and Methods In this cross-sectional study, 384 patients were selected through stratified random sampling with allocation proportionate to each city’s population. These patients were referred to level 2 in the frame of electronic referral system and received outpatient services by a specialist physician in the clinics of hospitals implementing the electronic referral system in Golestan province in 2019. This study was conducted in the cities of Bandar-e-Turkmen, Aq-Qala and Aliabad-e-Katoul, where the electronic health referral system had been fully. The population comprised 3 groups totaling approximately 11,004 people. The sample size allocated to each city was determined in view of the ratio of patients referred to level 2 in each city. Accordingly, the sample size selected included 84 subjects from Bandar-e-Turkmen City, 203 from AqQala is 203, and 115 from Aliabad. Having referred to these centers, we collected, from the patient registration office, the record of the patients whose family physician had referred them to level 2 and who had received the desired services. Then, the subjects were systematically and randomly selected according to the referral code registered in the system and the patient list. The data were collected through a two-part questionnaire. The first part of the questionnaire revolved around demographic variables, including age, sex, marital status, level of education, occupation and clinical and medical characteristics such as the number of visits to this clinic, type of disease and type of patients' insurance. The second part of the questionnaire assessed the patients' perceptions and expectations by 30 questions which were similar in content and number but different in wording. In this study, the validity of the questionnaire was confirmed by 10 experts including senior and mid-level managers and faculty members of Golestan University of Medical Sciences. Cronbach's alpha coefficient was calculated to determine the overall reliability of the questionnaire. The data were analyzed using SPSS software version 23. The data were analyzed descriptively through tables, number, frequency percentage for qualitative data, and Mean and Standard Deviation for quantitative data. In addition, we employed analytical statistics such as nonparametric mean comparison tests, in view of the normality assumption,) including Wilcoxon test, Mann-Whitney and Kruskal-Wallis and also Spearman correlation test to determine the intensity of correlation between the study variables. In the present study, the significance level of all tests was considered 0.05. Results Out of a total of 402 patients studied, information on only 384 patients was fully recorded (response rate 95.5%). The majority of subjects were female (74.5%), married (81.5%), high school graduate (24.9%), housewife (64.9%). The mean age of the patients was 37.17 ± 14.54 years, so that 62.4% of the subjects fell in the age bracket of 30-60 years. 53.6% of the patients had referred to the center more than once. 56.2% had rural insurance and the highest number of referrals had been made to gynaecologist (21.4%). The relationship between expectations and perceptions of service quality in all dimensions was statistically significant (P 〈 0.001). The results of Wilcoxon test showed that the gap between the patients' expectations and perceptions with a 95% probability was significant (P 〈 0.001) in all three cities and among all patients., found that. That is, there was a difference between the patients' expectations of service quality and their perceptions in the whole sample. The highest mean score in the expectations section was related to the guarantee and confidence dimension (4.49) and it was related to the tangible dimension in the perceptions section (4.10) is) while the lowest score is in the expectations and perceptions section related to the empathy dimension (4.34 and respectively. 77.3). After calculating the difference between the mean scores of perceptions and expectations, in all dimensions, the level of the patients' expectations of services was found higher than the level of perceptions with a negative gap. The largest gap in service quality was related to the empathy dimension (-0.57) and the lowest quality service gap was related to the tangible dimension (-0.38). There was no significant relationship between service quality gap and age groups, marital status, occupation groups, number of visits, type of insurance and type of illness (P 〉 0.05). But the gap in service quality was significantly associated with the patients' gender (P = 0.005) and education level (P = 0.028). So that the biggest gap was related to women and illiterate people. Also, the quality gap was different according to the city (P = 0.028), with the largest gap related to Aq-Qala city. Conclusion The results showed that the studied hospitals could not meet the expectations of the patients in any of the five components of service quality, with the perceived quality always lagging behind the expected quality. This highlights need to improve the quality of services through paying more attention to people in the community in order to deliver committed services reliably, accurately and correctly in a timely manner, as well as, enhancing the knowledge, etiquette and ability of employees to build trust and confidence in customers. Since at the time of the study, only three cities, Bandar-e-Turkmen, Aq-Qala and Aliabad-e-Katoul, were implementing an electronic referral system, it was not possible to study other cities in this field and the statistical population was outpatients from level 1 to level 2. A wider study should be conducted at the provincial level to include all referrals to family physicians at level one and all inpatient and outpatient referrals. In addition, the SERVQUAL questionnaire does not cover all the expectations, perceptions and beliefs of patients, so the use of qualitative study methods along with quantitative methods in future studies could provide a better understanding of the issue of quality. Practical implications of research According to the results of this study, it is suggested that officials and providers of health services should prioritize:- Continuous improvement and evaluation of service quality in planning;- Equipping medical centers with efficient and new equipment;- Providing services at the promised time and in the shortest time to clients;- Availability of staff and service providers when patients are referred;- Familiarity with the knowledge and skills of the day to meet the needs of clients and- Understanding the values and emotions of clients Ethical considerations study protocol, with the number IR.GOUMS.REC.1397.289, was ethically approved by the Research Ethics committee of Golestan University of Medical Sciences. At the time of data collection, respondents were assured that their information would remain confidential and the questionnaire was completed anonymously. Meanwhile, those who did not want to participate in the study were excluded from the study. Conflict of interest The authors state that there is no conflict of interest in the present study. Acknowledgement The Vice Chancellor for Research and Technology of Golestan University of Medical Sciences and the Research Center for Health Management and Social Development for approving the research plan with code 110602 and the assistance of officials and staff of selected hospitals in conducting this research plan are appreciated.