A baseline study on the assessment and perception of structured referral letters among urban hospitals in Rwanda

Abstract
Background: Patient referral is a process in which a healthcare provider decides to seek assistance due to the limitations of available skills, resources and services offered locally.
Objective: The goal of this study is to assess the formats, completeness of existing paper-based referral letters and the perception of healthcare provider to improve health information exchange, coordination, and continuity of care for the hospitals in the urban environment of Kigali.
Methods: A mixed methods research was conducted in eight public and three private healthcare facilities from July 2019 to July 2021 in three phases. i) A retrospective study was conducted with a purposive sampling method to select referral letters from patients’ files, every single variable that was completed was assigned a YES and missing variables were assigned a NO. Descriptive analyses were conducted. ii) A questionnaire was designed according to the contents of the referral letters and completed with healthcare providers and iii) Two focus group discussions were conducted.
Results: i) There were ten different referral letter formats in the eleven health facilities selected and few of them agreed with World Health Organization (WHO) referral note standards. A total of 2,304 referral letters were perused and the results show that the overall completeness of the referral letters varies between 46.0% and 97.7% with an average of 71.8%. ii) We collected 284 questionnaires; descriptive analysis was performed using excel 365. Overall, 345 constituents, 202 mandatory and 143 optional constituents were confirmed by the healthcare providers from the dataset, finally, iii) from the focus group discussions two themes emerged, the first one elucidated challenges with the existing referral system while the second suggested features to be considered in the development of the electronic referral system.
Conclusions: There were inconsistencies in the formats of referral letters used. Additionally, there were deficits in the completeness of referral letters. Information on healthcare providers' perceptions of the referral system were gathered, most importantly features to be included in the design and their expectation of the electronic referral system. Finally, lead to a proposal of the design of an electronic external referral form. A development of an electronic referral system will follow.