Overcoming Barriers to Electronic Referral Systems: A Multidisciplinary Approach to Enhancing Global Healthcare Delivery
DOI:
https://doi.org/10.62255/mjhp.v3i2.190Abstract
The integration of electronic referral (e-referral) systems into healthcare ecosystems offers significant potential to enhance care coordination, reduce inefficiencies, and improve patient outcomes. However, challenges persist across legal, technological, and social dimensions. A PRISMA-based Systematic Literature Review (SLR) highlights jurisdictional barriers, such as GDPR-HIPAA mismatches, with 40% of EU organizations facing hurdles in sharing data with U.S. partners. Stringent data localization laws in countries like Russia and China further complicate interoperability. Ethical frameworks, including beneficence and non-maleficence, are critical for trust in sensitive care areas. Technological gaps include uneven HL7 FHIR adoption, infrastructure limitations, and underutilization of AI and blockchain innovations. Estonia’s X-Road system demonstrates blockchain’s role in reducing referral wait times by 30%, while India’s e-Sanjeevani platform serves remote areas offline. Clinician resistance and digital literacy gaps necessitate tailored solutions. Escalating cyber threats demand robust measures like zero-trust architectures. Public-private partnerships, open-source platforms, and measurable outcomes (?80% clinician adoption, <48-hour approval times) are vital. Pandemic-resilient systems and sustainable cloud solutions further emphasize scalability and equity. Harmonized policies and inclusive stakeholder engagement are essential for global success.
Downloads
Keywords:
: E-referral systems, GDPR, HIPAA, HL7 FHIR, Blockchain, AI-driven triage, Data security, Digital literacy, Public-private partnerships, Pandemic resilience, Environmental sustainability.References
Agu, E. E., Obiki-Osafiele, A. N., & Chiekezie, N. R. (2024). Addressing advanced cybersecurity measures for protecting personal data in online financial transactions. World Journal of Engineering and Technology Research. https://doi.org/10.53346/wjetr.2024.3.1.0052
Ahn, G., Jang, J., Choi, S., & Shin, D. (2024). Research on Improving Cyber Resilience by Integrating the Zero Trust Security Model With the MITRE ATT&CK Matrix. IEEE Access, 12, 89291–89309. https://doi.org/10.1109/ACCESS.2024.3417182
Al-Agtash, S., & Barbera, R. (2019). Interoperable e-Infrastructure Services in Arabia. Journal of Computer and Communications. https://doi.org/10.4236/JCC.2019.75003
Alrajeh, N. (2013). Interoperability and Security Challenges in e-Health Systems. Family Medicine and Medical Science Research, 1, 1–2. https://doi.org/10.4172/2327-4972.1000E103
Alsuwaidi, N., Alharmoodi, N., & Hamadi, H. (2024). The Transformative Impact of Zero-Trust Architecture on Healthcare Security. 2024 2nd International Conference on Cyber Resilience (ICCR), 1–8. https://doi.org/10.1109/ICCR61006.2024.10532794
Ameis, S., Lai, M., Mulsant, B., & Szatmari, P. (2020). Coping, fostering resilience, and driving care innovation for autistic people and their families during the COVID-19 pandemic and beyond. Molecular Autism, 11. https://doi.org/10.1186/s13229-020-00365-y
Angeles, R., & Nath, R. (2007). Business?to?business e?procurement: success factors and challenges to implementation. Supply Chain Management, 12, 104–115. https://doi.org/10.1108/13598540710737299
Bambury, N., Zhang, M., McCarthy, T., Dawkins, I., Burke, L., Tierney, P., Walsh, P., Redmond, P., Mullooly, M., Murray, D., & Bennett, K. (2024). Impact of the COVID-19 pandemic on electronic referrals to rapid access clinics for suspected breast, lung and prostate cancers in Ireland. The European Journal of Public Health, 34, 908–913. https://doi.org/10.1093/eurpub/ckae092
Bente, B., Van Dongen, A., Verdaasdonk, R., & Van Gemert-Pijnen, J. (2024). eHealth implementation in Europe: a scoping review on legal, ethical, financial, and technological aspects. Frontiers in Digital Health, 6. https://doi.org/10.3389/fdgth.2024.1332707
Bernstam, E., Warner, J., Krauss, J., Ambinder, E., Rubinstein, W., Komatsoulis, G., Miller, R., & Chen, J. (2022). Quantitating and assessing interoperability between electronic health records. Journal of the American Medical Informatics Association?: JAMIA. https://doi.org/10.1093/jamia/ocab289
Bjurling-Sjöberg, P., Göras, C., Lohela-Karlsson, M., Nordgren, L., Källberg, A.-S., Castegren, M., Mellgren, E. C., Holmberg, M., & Ekstedt, M. (2021). Resilient performance in healthcare during the COVID-19 pandemic (ResCOV): study protocol for a multilevel grounded theory study on adaptations, working conditions, ethics and patient safety. BMJ Open, 11. https://doi.org/10.1136/bmjopen-2021-051928
Carroll, Á., Twomey, V., & White, B. (2018). Identifying barriers to Implementation of New Care Models, a Multi-Stakeholder Engagement Study. International Journal of Integrated Care. https://doi.org/10.5334/IJIC.S2048
Cartier, Y., Fichtenberg, C., & Gottlieb, L. (2020). Implementing Community Resource Referral Technology: Facilitators And Barriers Described By Early Adopters. Health Affairs, 39 4, 662–669. https://doi.org/10.1377/hlthaff.2019.01588
Chouvarda, I., Goulis, D., Lambrinoudaki, I., & Maglaveras, N. (2015). Connected health and integrated care: Toward new models for chronic disease management. Maturitas, 82 1, 22–27. https://doi.org/10.1016/j.maturitas.2015.03.015
Christiansen, E., Skipenes, E., Hausken, M., Skeie, S., Østbye, T., & Iversen, M. (2017). Shared Electronic Health Record Systems: Key Legal and Security Challenges. Journal of Diabetes Science and Technology, 11, 1234–1239. https://doi.org/10.1177/1932296817709797
Cijvat, C., Cornet, R., & Hägglund, M. (2021). Factors Influencing Development and Implementation of Patients’ Access to Electronic Health Records—A Comparative Study of Sweden and the Netherlands. Frontiers in Public Health, 9. https://doi.org/10.3389/fpubh.2021.621210
De Grood, C., Raissi, A., Kwon, Y., & Santana, M. (2016). Adoption of e-health technology by physicians: a scoping review. Journal of Multidisciplinary Healthcare, 9, 335–344. https://doi.org/10.2147/JMDH.S103881
De Pietro, C., & Francetic, I. (2017). E-health in Switzerland: The laborious adoption of the federal law on electronic health records (EHR) and health information exchange (HIE) networks. Health Policy, 122 2, 69–74. https://doi.org/10.1016/j.healthpol.2017.11.005
Din, I., Khan, K. H., Almogren, A., Zareei, M., & Díaz, J. A. P. (2024). Securing the Metaverse: A Blockchain-Enabled Zero-Trust Architecture for Virtual Environments. IEEE Access, 12, 92337–92347. https://doi.org/10.1109/ACCESS.2024.3423400
Doleman, G., De Leo, A., & Bloxsome, D. (2023). The impact of pandemics on healthcare providers’ workloads: A scoping review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.15690
Esquivel, A., Sittig, D., Murphy, D., & Singh, H. (2012). Improving the Effectiveness of Electronic Health Record-Based Referral Processes. BMC Medical Informatics and Decision Making, 12, 107. https://doi.org/10.1186/1472-6947-12-107
Faro, J., Yue, K.-L., Leach, H., Crisafio, M., Lemon, S., Wang, B., McManus, D., & Sadasivam, R. (2023). Development and pilot testing of a clinic implementation program delivering physical activity electronic referrals to cancer survivors. Translational Behavioral Medicine. https://doi.org/10.1093/tbm/ibad035
Gagnon, M., Ngangue, P., Payne-Gagnon, J., & Desmartis, M. (2016). m-Health adoption by healthcare professionals: a systematic review. Journal of the American Medical Informatics Association?: JAMIA, 23 1, 212–220. https://doi.org/10.1093/jamia/ocv052
García, I., Seco-Meseguer, E., Borobia, A., & Carcas-Sansuán, A. (2023). Implementing pharmacogenetics in clinical trials: considerations about current methodological, ethical, and regulatory challenges. Expert Review of Clinical Pharmacology, 17, 1–10. https://doi.org/10.1080/17512433.2023.2293999
Grechenig, T., Tappeiner, B., & Wujciow, A. (2008). Challenging interoperability and bandwidth issues in national e-Health strategies by a bottom-up approach: Establishing a performant IT infrastructure network in a Middle East State. HealthCom 2008 - 10th International Conference on e-Health Networking, Applications and Services, 148–155. https://doi.org/10.1109/HEALTH.2008.4600126
Haun, J., Nakase-Richardson, R., Cotner, B., Agtarap, S., Martin, A., Tweed, A., Hanks, R., Wittine, L., Bergquist, T., & Hoffman, J. (2024). Stakeholder Engagement to Identify Implementation Strategies to Overcome Barriers to Delivering Chronic Pain Treatments: A NIDILRR and VA TBI Model Systems Collaborative Project. Journal of Head Trauma Rehabilitation, 39. https://doi.org/10.1097/HTR.0000000000000920
Hegde, M., Rao, R., & Nikhil, B. (2022). DDMIA: Distributed Dynamic Mutual Identity Authentication for Referrals in Blockchain-Based Health Care Networks. IEEE Access, 10, 78557–78575. https://doi.org/10.1109/access.2022.3193238
Huettemann, R., Sevov, B., Meister, S., & Fehring, L. (2024). Understanding citizens’ attitudes within user-centered digital health ecosystems: A sequential mixed method methodology including a web-survey. Digital Health, 10. https://doi.org/10.1177/20552076241255929
Huffman, E., Athanasiadis, D., Anton, N., Haskett, L., Doster, D., Stefanidis, D., & Lee, N. (2020). How resilient is your team? Exploring healthcare providers’ well-being during the COVID-19 pandemic. American Journal of Surgery, 221, 277–284. https://doi.org/10.1016/j.amjsurg.2020.09.005
Igwama, G. T., Olaboye, J. A., Maha, C. C., Ajegbile, M. D., & Abdul, S. (2024). Integrating electronic health records systems across borders: Technical challenges and policy solutions. International Medical Science Research Journal. https://doi.org/10.51594/imsrj.v4i7.1357
Kabir, M. J., Heidari, A., Honarvar, M., & Khatirnamani, Z. (2024). Electronic referral system policy analysis: a qualitative study in the context of Iran. Primary Health Care Research & Development, 25. https://doi.org/10.1017/S1463423624000239
Khayyat, S., & Nazar, H. (2023). Qualitative investigation of barriers to providing an electronic hospital to community pharmacy referral service for discharged patients. PLOS ONE, 18. https://doi.org/10.1371/journal.pone.0283836
Klischewski, R. (2011). Architectures for Tinkering? Contextual Strategies towards Interoperability in E-government. J. Theor. Appl. Electron. Commer. Res., 6, 26–42. https://doi.org/10.4067/s0718-18762011000100004
Kruse, C., Kristof, C., Jones, B., Mitchell, E., & Martinez, A. (2016). Barriers to Electronic Health Record Adoption: a Systematic Literature Review. Journal of Medical Systems, 40. https://doi.org/10.1007/s10916-016-0628-9
Kruse, C., Stein, A., Thomas, H., & Kaur, H. (2018). The use of Electronic Health Records to Support Population Health: A Systematic Review of the Literature. Journal of Medical Systems, 42. https://doi.org/10.1007/s10916-018-1075-6
Li, E., Clarke, J., Neves, A., Ashrafian, H., & Darzi, A. (2021). Electronic Health Records, Interoperability and Patient Safety in Health Systems of High-income Countries: A Systematic Review Protocol. BMJ Open, 11. https://doi.org/10.1136/bmjopen-2020-044941
Liddy, C., De Man, G., Moroz, I., Afkham, A., Mercer, J., & Keely, E. (2020). Effective Integration of an eConsult Service into an Existing Referral Workflow Within a Primary Care Clinic. Telemedicine Journal and E-Health?: The Official Journal of the American Telemedicine Association. https://doi.org/10.1089/tmj.2019.0014
Liu, Y., Su, Z., Peng, H., Xiang, Y., Wang, W., & Li, R. (2024). Zero Trust-Based Mobile Network Security Architecture. IEEE Wireless Communications, 31, 82–88. https://doi.org/10.1109/MWC.001.2300375
Maksimovic, M., & Vujovic, V. (2017). Internet of Things Based E-health Systems: Ideas, Expectations and Concerns. 241–280. https://doi.org/10.1007/978-3-319-58280-1_10
Mazón-Ramosa, Román-Regoa, A., Díaz-Fernándeza, B., Portela-Romerob, M., Garcia-Vegaa, Bastos-Fernándeza, M., Rey-Aldanab, D., Lage-Fernándezb, R., Cinza-Sanjurjob, & González-Juanateya, J. (2023). Revista Clínica Española. https://consensus.app/papers/revista-clínica-española-mazón-ramosa-román-regoa/f4c9f3ff1784509f90601c89eae93343/
McGovern, M., Quinlan, M., Doyle, G., Moore, G., & Geiger, S. (2018). Implementing a National Electronic Referral Program: Qualitative Study. JMIR Medical Informatics, 6. https://doi.org/10.2196/10488
Muller, A., Hafstad, E., Himmels, J., Smedslund, G., Flottorp, S., Stensland, S., Stroobants, S., Van De Velde, S., & Vist, G. (2020). The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review. Psychiatry Research, 293, 113441. https://doi.org/10.1016/j.psychres.2020.113441
Murphy, J., Qureshi, O., Endale, T., Esponda, G. M., Pathare, S., Eaton, J., De Silva, M., & Ryan, G. (2021). Barriers and drivers to stakeholder engagement in global mental health projects. International Journal of Mental Health Systems. https://doi.org/10.1186/s13033-021-00458-y
Naseriasl, M., Adham, D., & Janati, A. (2015). E-referral Solutions: Successful Experiences, Key Features and Challenges- a Systematic Review. Materia Socio-Medica, 27, 195–199. https://doi.org/10.5455/msm.2015.27.195-199
Nguyen, D., Pathirana, P., Ding, M., & Seneviratne, A. (2019). Blockchain for Secure EHRs Sharing of Mobile Cloud Based E-Health Systems. IEEE Access, 7, 66792–66806. https://doi.org/10.1109/ACCESS.2019.2917555
Osman, M., Schick-Makaroff, K., Thompson, S., Bialy, L., Featherstone, R., Kurzawa, J., Zaidi, D., Okpechi, I., Habib, S., Shojai, S., Jindal, K., Braam, B., Keely, E., Liddy, C., Manns, B., Tonelli, M., Hemmelgarn, B., Klarenbach, S., & Bello, A. (2019). Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review. BMJ Global Health, 4. https://doi.org/10.1136/bmjgh-2019-001629
Pandey, P., & Litoriya, R. (2020). Implementing healthcare services on a large scale: Challenges and remedies based on blockchain technology. Health Policy and Technology, 9, 69–78. https://doi.org/10.1016/j.hlpt.2020.01.004
Quinlan, M., McGovern, M., Doyle, G., & Geiger, S. (2017). Implementing integrated care – lessons from the national implementation of general eReferrals in Ireland. International Journal of Integrated Care, 17, 232. https://doi.org/10.5334/IJIC.3542
Ross, J., Stevenson, F., Lau, R., & Murray, E. (2015). Exploring the challenges of implementing e-health: a protocol for an update of a systematic review of reviews. BMJ Open, 5. https://doi.org/10.1136/bmjopen-2014-006773
Salloum, R., Shenkman, E., Louviere, J., & Chambers, D. (2017). Application of discrete choice experiments to enhance stakeholder engagement as a strategy for advancing implementation: a systematic review. Implementation Science?: IS, 12. https://doi.org/10.1186/s13012-017-0675-8
Serbanati, L., Ricci, F., Mercurio, G., & Vasil??eanu, A. (2011). Steps towards a digital health ecosystem. Journal of Biomedical Informatics, 44 4, 621–636. https://doi.org/10.1016/j.jbi.2011.02.011
Serrano, A., Guzman, J., Xydopoulos, G., & Tarhini, A. (2018). Analysis of Barriers to the Deployment of Health Information Systems: a Stakeholder Perspective. Information Systems Frontiers, 22, 455–474. https://doi.org/10.1007/S10796-018-9869-0
Sonkamble, R., Phansalkar, S., Potdar, V., & Bongale, A. (2021). Survey of Interoperability in Electronic Health Records Management and Proposed Blockchain Based Framework: MyBlockEHR. IEEE Access, PP, 1. https://doi.org/10.1109/ACCESS.2021.3129284
Sultana, M., Hossain, M. A., Laila, F., Taher, K., & Islam, M. (2020). Towards developing a secure medical image sharing system based on zero trust principles and blockchain technology. BMC Medical Informatics and Decision Making, 20. https://doi.org/10.1186/s12911-020-01275-y
Tan, E., Lerouge, E., Du Caju, J., & Du Seuil, D. (2023). Verification of Education Credentials on European Blockchain Services Infrastructure (EBSI): Action Research in a Cross-Border Use Case between Belgium and Italy. Big Data Cogn. Comput., 7, 79. https://doi.org/10.3390/bdcc7020079
Thantharate, P., & Thantharate, A. (2023). ZeroTrustBlock: Enhancing Security, Privacy, and Interoperability of Sensitive Data through ZeroTrust Permissioned Blockchain. Big Data Cogn. Comput., 7, 165. https://doi.org/10.3390/bdcc7040165
Vazirani, A., O’Donoghue, O., Brindley, D., & Meinert, E. (2019). Implementing Blockchains for Efficient Health Care: Systematic Review. Journal of Medical Internet Research, 21. https://doi.org/10.2196/12439
Walle, A. D., Demsash, A. W., Adem, J. B., Wubante, S. M., Shibabaw, A. A., Mamo, D. N., Kebede, S. D., Muluneh, A. A., Mengiste, M., Gebeyew, A. S., Butta, F. W., Chereka, A. A., Dubale, A. T., Kassie, S. Y., & Ferede, T. A. (2023). Exploring facilitators and barriers of the sustainable acceptance of e-health system solutions in Ethiopia: A systematic review. PLOS ONE, 18. https://doi.org/10.1371/journal.pone.0287991
Wen, X., Song, Q., OuYang, S., Yao, Z., & Luo, Y. (2024). Novel use of structural equation modeling to examine the development of a framework of patient-centered two-way referral systems for building digital subjective well-being healthcare: A cross-sectional survey in Central China. Digital Health, 10. https://doi.org/10.1177/20552076241253079
Zdravkovi?, M., & Jardim-Gonçalves, R. (2018). Model-driven data-intensive Enterprise Information Systems. Enterprise Information Systems, 12, 910–914. https://doi.org/10.1080/17517575.2018.1526327
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Indi Dwi Shofi Yanti, Ghoniya Ilmi Agita, Dewa Bagus Prasetyo, Nayla Putri Yuwana, Nelsya Gita Aurellia Hadi, Raudhatunnisa Agustina, Syelova Oktoprime Nur Ramadhany, Wesi Wasella Kiremi, Zahra Nuriyatul Izzah, Nurul Evi, Ema Novita Deniati

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.






