Family Medicine & Primary Care Review 2023; 25(1): 73–79, https://doi.org/10.5114/fmpcr.2023.

125496

ISSN 1734-3402, eISSN 2449-8580

ORIGINAL PAPERS © Copyright by Wydawnictwo Continuo

Key factors in the success of an electronic patient referral

system in the family physician programme: what can we
do for the future?
Fatemeh Tajari1, A–F, Ghahraman Mahmoudi2, A, B, D–F, Fatemeh Dabbaghi2, A–C, E–F,
ORCID ID: 0000-0003-4069-9584 ORCID ID: 0000-0003-3769-4379 ORCID ID: 0000-0003-3481-1322

Jamshid Yazdani-Charati 3, A, C–E

, Hamidreza Safikhani4, A, B, F
ORCID ID: 0000-0002-4721-225X ORCID ID: 0000-0001-5459-1326

1
Sari Branch, Islamic Azad University, Sari, Iran
2
Hospital Administration Research Centre, Sari Branch, Islamic Azad University, Sari, Iran
3
Biostatistics Department, Health Science Research Centre, Addiction Institute, Mazandaran University of Medical
Sciences, Sari, Iran
4
Economics & Health Management, Strategic Council at National Research Network for Policy Making, Health
Economics Association of Iran, Tehran, Iran

A – Study Design, B – Data Collection, C – Statistical Analysis, D – Data Interpretation, E – Manuscript Preparation, F – Literature
Search, G – Funds Collection

Summary Background. The electronic referral system (e-Referral) is an initial change in the way health care is provided. There are
many factors that prevent the spread of such technologies in developing countries.
Objectives. Determining the key factors in the success of the electronic referral system in Iran.
Material and methods. This qualitative study was conducted in two phases (semi-structured interview and expert panel). The research
participants included 42 people for the interview and 6 local experts, who were selected via the purposive sampling method (stratified
sampling) and had at least three years of work experience. Data was collected using in-depth semi-structured interviews which were
continued until data saturation. Next, the content analysis method was used to analyse the data. Validity and reliability of the data
were determined based on the Guba and Lincoln including acceptability, transferability, reliability and verifiability. Two professors, as
qualitative research experts, also verified the credibility of the data through accurate and stepwise control of the research process.
Finally, an expert panel meeting was conducted to refine and improve the categorisation of key factors.
Results. The analysis of collected data resulted in the extraction of 6 main themes, 18 subthemes and 47 codes. The main themes
included resource management, information technology management, rules and regulations, stakeholder satisfaction and advocacy,
domestication and payment mode. Subthemes included management of financial, human, physical and equipment resources, intel-
ligence, security, information exchange speed, information integrity, data access, judicial and insurance laws, health service guidelines,
organisational culture, community culture, performance-based payment, etc.
Conclusions. This study offered rich documentation of the implementation of a successful e-Referral system, the availability of which in
an information society is essential and will assist managers and policymakers in the successful implementation of the e-Referral system.
Key words: referral and consultation, electronic health record, health information system, health services.

Tajari F, Mahmoudi G, Dabbaghi F, Yazdani-Charati J, SafiKhani H. Key factors in the success of an electronic patient referral system in the
family physician programme: what can we do for the future? Fam Med Prim Care Rev 2023; 25(1): 73–79, doi: https://doi.org/10.5114/
fmpcr.2023.125496.

Background addressing such issues, as in other areas, there has been an in-
creasing demand to use information and communication tech-
The evolving needs of society have made the reform and nology in health systems, resulting in electronic referrals to be
evolution of health systems a necessity in all countries [1]. recognised as one of the best solutions to replace paper referrals
A revolution in the field of medicine, techniques, enhancement [5]. The electronic referral system (e-Referral) has the potential
and knowledge has been impacting all aspects of health care to be a transformative technology in the healthcare system [1].
[1, 2]. In the family physician programme (FPP) in Iran, the lev- E-Referral systems have been designed with the dual purpose
elling of services prevents frequent and unnecessary referrals of decreasing wait times and improving workflow efficiency.
to specialised centres and prevents the loss of material and Evidence about the clinical and economic value enabled through
human resources. Moving along the referral path also results the use of e-Referral is limited [6–8]. On the other hand, access
in patients receiving the services they need with better qual- to specialty care remains a challenge for primary care providers
ity at the relevant levels (levels one, two and three) [3]. Paper and patients. Implementation of e-Referral or consultation sys-
referral processes suffer specific limitations, such as insufficient tems provides an opportunity for innovations in the delivery of
information, missing or incomplete paper records, medica- specialty care [9, 10]. Along with other benefits, the implementa-
tion errors due to illegible handwriting and the lack of capac- tion of an e-Referral can certainly improve the country’s health
ity to track referrals, duplicate results and communication or economy [11–14]. Adopting and promoting information and
feedback between referral providers and professionals [4]. For communication technology (ICT) [15], as well as Electronic Health

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
(CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/).
 74 F. Tajari et al. • Key factors in the success of the electronic referral system

Records (EHRs) [16], in healthcare delivery are growing rapidly in minutes. To analyse the data, recorded interviews were listened
most developing countries, including Ghana [17]. In a develop- to immediately after each interview to gain insight into the par-
ing country, the implementation of e-health is associated with ticipants’ experiences. After listening to the audio file of the
the lack of a regulatory policy, high levels of training and culture interview and transcribing the contents, the manuscripts were
gap, challenges in using technology and many other factors, such checked again with the content of the tape.
as e-health education before and during the service, the devel-
opment of e-health performance policies to make the use of Data analysis
e-health mandatory and the challenges of data sharing [18]. The As Graneheim and Lundman explain, qualitative content an-
results of the implementation of the electronic referral system alytical approaches focus on analyzing both the explicit or mani-
in the Greek Public Healthcare Organisation showed that the fest content of a text as well as interpretations of the 'latent
implementation of an electronic referral system could provide content' of texts ­– that which can be interpreted or interpolated
benefits, such as valid information, a faster referral process, im- from the text, but is not explicitly stated in it [24]. It suggests five
provement in quality of services and minimisation of the risk of steps to analyse qualitative data, as follows: writing down the
misinterpretation due to illegibility of handwriting [19]. In a study whole interview immediately after each interview, reading the
conducted by Azamar-Alonso et al., it was shown that improves whole text of the interview to get a general understanding of its
communication between primary caregivers and specialists and content, determining the content of data and initial codes, cat-
decreases wait times [20]. In another study, it was found that al- egorising the similar initial codes in more general categories and
though electronic referrals were touted as a safer solution than determining the hidden concept of the data [25]. The transcripts
paper referrals, security remained a concern. Health centres can of interviews were read several times, and the initial codes were
influence the acceptance of e-Referrals by encouraging the use of extracted. The initial codes related to each transcript were then
electronic systems [1]. According to the foreword, it is very valu- merged, and based on the similarities, they formed subcatego-
able to have related information in this area for decision-making ries, categories and themes. Lincoln and Guba suggested four
and policymaking by officials in the field related to medical in- criteria to ensure trustworthiness in qualitative research: cred-
formation technology. Recently, this programme has been used ibility, dependability, confirmability, and transferability; these
in several provinces of Iran. Experiences in these provinces will four criteria parallels the positivists' criteria of internal validity,
be used to explore the most important requisites for successful reliability, objectivity, and external validity respectively [26]. In
implementation of Iran’s e-referral system. Therefore, this study content analysis, more attention is paid to the hidden themes of
was conducted with the aim of investigating the key factors in the the interviews, and inferring and extracting meaning from it is
success of an electronic patient referral system in the family phy- of interest. The researcher attempted to increase the credibility
sician programme in Iran. of the research through long-term engagement with the subject
and sufficient experience concerning the field under study, as
Material and methods well as through sufficient participation and interaction with the
participants, gathering valid information and confirming the in-
Study design and setting formation of the participants. Double-step repetition, data col-
lection and analysis and reviews of supervisors, counsellors and
This was a qualitative study conducted in two phases (semi- experts were performed to increase research dependability.
structured interview and expert panel) in 2021 in the Iranian To increase data validity, the approval of the faculty members
health system. Qualitative studies can explain and predict im- of the university and their additional comments were also used.
portant phenomena and effectively relate this to the quan-
titative parts of a larger study to improve health services and Phase 2: Expert panel
develop a health policy. As a systematic method, this scheme
was used to provide an in-depth description of the phenom- After classifying the key factors in the electronic referral
enon which was suitable for evaluating people’s experiences on system, the research team entered the draft version of the cat-
a particular subject, and this is more useful when the theory and egorisation into the expert panel phase. An expert panel, includ-
studies related to the phenomenon under study are limited [21, ing 6 local Iranian experts in e-referral systems, reviewed and
22]. The research team extracted and sub-themes the main data discussed the content of the categorisation factors. The meet-
from the interviews in the first phase. In the second phase, the ing of the expert panel was arranged in one session and lasted
result of the sub-themes was refined and improved through an around two hours. The opinions of experts were recorded by
expert panel meeting. a digital audio recorder and then used by the research team to
merge, add and remove the factors. For the sake of rigor in this
Phase 1: Semi-structured interview phase, data transferability and reliability were also used from
a peer review expert check, and immersion.
Study participants and selection
Ethical consideration
Family Medicine & Primary Care Review 2023; 25(1)

By using a purposive sampling method (stratified sampling)

[23], experts were selected from the fields of health policy,
health services administration, health economics and senior For conducting the present study, a research ethics code of
managers of the Ministry of Health, service providers and recipi- IR.IAU.CHALUS.REC.1397.025 was obtained from the Research
ents. Selection criteria for the sample included knowledge and Committees of the target universities. Meanwhile, the par-
experience in the field of e-Referral with at least three years of ticipants completed consent forms, granting them the right to
professional experience, and for service recipients, at least one withdraw from the study at any stage of the study and observ-
transfer using the electronic referral system. After interviewing ing the confidentiality of their information.
42 people, we reached information saturation.
Results
Data collection
Data was collected using semi-structured in-depth inter- Demographic characteristics
views individually in a calm environment until data saturation
was reached. In a qualitative study, data collection is necessary The study sample consisted of 42 stakeholders at different
until the researcher reaches theoretical saturation. This means executive levels. Among the 42 study participants, the majority
that no new information will be obtained as the work continues. (80.95%) were male, with 24–30 years of work experience (33.33%).
All interviews were recorded with the permission of the partici- The highest percentage (33.33%) of participants held management
pants. The duration of the interviews was between 30 and 45 positions, while 52.38% were medical doctors (Table 1).
 F. Tajari et al. • Key factors in the success of the electronic referral system 75

Table 1. Demographic characteristics of participants

Variable Grouping Frequency Variable Grouping Frequency/
(percentage) (percentage)
Gender Male 34 (80.95) Job Position Manager 14 (33.33)
Female 8 (19.05) University faculty member 7 (16.66)
Number of participants Experts 38 (90.47) Specialist in hospital 5 (11.90)
Electronic referral Medical doctor in the health
service recipients 4 (9.52) centre 6 (14.28)
Work experience for 3–10 7 (16.6) Electronic referral service
experts (years) provider 6 (14.28)
e-Referral service recipient 4 (9.52)
10–17 12 (28.57) Workplace Ministry of Health 4 (9.52)
17–24 9 (21.42) University of Medical Sciences 17 (40.47)
24–30 14 (33.33) Health centre 9 (21.42)
Level of education Medical doctor 22 (52.38) Hospital 8 (19.04)
Health insurance 2 (4.76)
BA 4 (9.55) Management and Social Health
MA 4 (9.55) Research Centre 2 (4.76)
PH. D 12 (28.57)

Table 2. Components extracted from the experiences of study participants

Theme Sub-Themes Codes
Resource manage- Human resource manage- • Supplying and distributing the required manpower in proportion to the popula-
ment ment tion covered
• Increasing the capability of human resources to implement the e-Referral
system
• Decreasing the workload of employees
Management of financial • Allocating financial resources
resources • Reducing the administrative costs of the referral system
• Using auto stops in electronic referrals to reduce the operating costs of the
health system
• Allocating research credit to evaluate the performance of the e-Referral system
Physical and equipment • Supplying the required hardware infrastructure and equipment
resources • Providing the required ICT and software infrastructure
Information tech- Information security • Observing patient privacy
nology manage- • Backing up patient information and facilitating the ability to retrieve patient
ment information
• Building trust regarding information security with recipients and service provid-
ers
Speed ​​of information ex- • Reducing referral processing time
change • Implementing web server standards
• Matching data exchange codes between different levels
Information integrity • Connecting level one, specialised and paraclinical services to the e-Referral
system
• Integrating data at service delivery levels
• Providing the ability to monitor the referral process in the e-Referral system
Family Medicine & Primary Care Review 2023; 25(1)

Access to information • Providing patients with access to their information

• Providing access to patient care records
• Developing and applying standards for managerial access to information of the
e-Referral system at different levels of service delivery
• Designing standard processes and standard graphs of the workflow of the elec-
Data governance tronic referral system
• Reengineering e-Referral system processes based on patient needs assessment
Process engineering • Organising data and information in order to increase the efficiency and effec-
tiveness of the e-Referral system
• Providing information products using data from the e-Referral system
• Using information from the e-Referral system in policymaking
Satisfaction and Satisfaction and advocacy • Developing and implementing strategies to attract the informed participation
advocacy of stake- organisations and institu- of managers and policymakers in related public and private organisations and
holders related tions related to the e-Referral institutions and insurance
to the e-Referral programme • Analysing and presenting credible reports for participation in the decision-mak-
programme ing of managers and policymakers
 76 F. Tajari et al. • Key factors in the success of the electronic referral system

Table 2. Components extracted from the experiences of study participants

Theme Sub-Themes Codes
Satisfaction and Satisfaction and advocacy • Attracting the informed participation of service providers to implement the
advocacy of stake- service providers e-Referral system
holders related • Attracting the participation of service providers in the preparation of rules,
to the e-Referral regulations and instructions
programme • Involving service providers at different levels in the design of the payment
system
Satisfaction and advocacy • Involving the community in the e-Referral system
service recipients • Conducting a community needs assessment regarding the e-Referral system
Culturalisation Culturalisation in related • Identifying the processes of organisations related to the programme
organisations • Involving employees of organisations related to the programme
• Observing the levelling and structure of service delivery within the organisa-
tions related to the programme
Culturalisation in service • Having the participation of service providers
providers • Observing the levelling and structure of service delivery within the service
providers
Community culture • Causing people to believe in the benefits of an e-Referral system
• Increasing community ICT literacy to implement an e-Referral system
Rules, regulations Health services rules and • Developing and implementing insurance regulations in an integrated and coor-
and instructions insurance rules dinated manner
• Codifying e-Referral system rules in upstream documents and country develop-
ment plans
• Developing rules and guidelines for health services (guidelines) for the
e-Referral system
Judicial and legal laws • Developing and applying judicial laws for the e-Referral system
• Observing the right combination of power, encouragement and punishment to
guide the owners of the process
Payment system Payment for performance in • Ensuring the existence of a specific process for paying employees in the
the e-Referral programme e-Referral system
• The proportionality of the payment of employees with their performance in
order to achieve the goals of the electronic referral system
Family Medicine & Primary Care Review 2023; 25(1)

Figure 1. Components extracted from the experiences of study participants

The findings of the study were classified into 6 main themes, Resource management
18 sub-themes and 47 codes that comprised the key factors in
the success of an electronic patient referral system in the family Healthcare systems at international levels have limited re-
physician programme in Iran. (Table 2 and Figure 1). sources, so the truthful allocation of sources, financial resource
 F. Tajari et al. • Key factors in the success of the electronic referral system 77

management and equipment resource management are key el- 21 pointed to the importance of culture building in related in-
ements within the decision-making process. “… As an internal stitutions and organizations: “In terms of the social aspects of
medicine specialist, I had to examine about 40 patients and did the electronic referral system, we must inform the people that
not have enough time to examine them. Therefore, the quality the change in the referral system is in your favor and inform the
and quantity of patient care decreases due to the high number people about its benefits. This culture building should be done
of visits and lack of time. Thus, by distributing specialised hu- before launching the electronic referral system”.
man resources, it is possible to facilitate the provision of fair Raising the IT literacy of the society, changing peoples’ at-
and favourable health care … ”(P 8). “Our main goals in the elec- titudes and changing their behaviour are some of the issues
tronic referral system are to organise services and to reduce the that should be considered in culture building. “Education and
costs of the health system … ”(P 5). “If the referral system is fully culturalisation should be provided to the community before any
implemented, it must provide all the requirements of it. Elec- change is made …” (P 39).
tronic health systems need a series of tools and infrastructure
that are at level 1 and 2 …” (P 9). Rules, regulations and instructions

Information technology management Developing rules and guidelines, as well as assigning tasks
to each level of the health structure, prevent duplication of
Like any other information and communication technology work and wasting resources. Health services rules, insurance
(ICT) systems, numerous problems have been identified in the rules, judicial and legal laws were among the sub-areas that
implementation of the e-Referral system. Topics related to in- were considered by the study participants. “The structure of
formation technology include information security, information service delivery should be considered as a principle and prior-
exchange rates, information integrity, information access, pro- ity by the senior government official who is the president, and
cess design and data management. “In the care provided to the the High Council of Local Health should approve these policies
patient and the service provider, access to previous and current and announce them that all departments and organisations are
data becomes very important …” (P 23). “The lack of security obliged to implement it…” (P 2). “The formulation and develop-
in e-health systems has led to the disclosure of large amounts ment and application of judicial and legal laws for the e-Referral
of personal information, leading to patient dissatisfaction and system and the correct combination of power, encouragement
reduced trust in the e-health system and e-referral services …” and punishment to guide the owners of the process in the des-
(P 18). “One of the achievements of electronic processing is that ignated directions in e-Referral can be very effective …” (P 37).
we collect health information simultaneously so that at least
the service provider can plan treatment with knowledge of the Payment system
individual’s background …” (P 3). He also said: “In the service
provider, access to previous and recent data becomes very im- A payment system is one of the main tools used to support
portant. With electronic referral, information for patients or the healthcare reform. In the interview, it was repeatedly mentioned
service provider can be accessible …”. “The design of standard that in order to improve the e-Referral process, it should be ac-
processes and the existence of standard workflow diagrams and companied by changes in payment systems. “ Payment models
process re-engineering based on patient needs assessment is should be designed with the help of doctors and specialists. We
one of the issues that should be considered in the implementa- have to look at the evidence and the experience of the world
tion of the e-Referral system …” (P 30). but, at the same time, review it with the help of experts ...” (P 1).

Satisfaction and advocacy of stakeholders related Discussion

to the e-Referral programme
In the present study, using the opinions of experts, 6 main
One of the topics mentioned in the interviews is the satis- themes, 18 sub-themes and 47 codes were identified as key re-
faction and advocacy of stakeholders, which includes organisa- quirements for the successful implementation of the e-Referral
tions and institutions related to the programme, service pro- system.
viders and service recipients, etc. Advocacy organisations and In order to manage the costs of the health system and the
institutions related to the e-Referral programme are among the correct implementation of the e-Referral system, proper plan-
sub-themes in the e-Referral system, as mentioned by almost all ning must be done [27]. To gain higher access to the health sys-
interviewees (Ministry of Health, service providers and service tem, making a proper plan and fair distribution of specialised
recipients). “When we want to set up an e-Referral system, we personnel is critical [17]. In the referral system, electronic coor-
have to see if we already have advocated stakeholders. Have we dination and integration of information among healthcare pro-
analysed the stakeholders? Have we given them a role? These viders, access to patient records and the possibility of tracking
Family Medicine & Primary Care Review 2023; 25(1)

are the questions that should be considered in the implementa- referrals can lead to continued care, while the quality of care,
tion phase of the e-Referral system …” (P 3). “The most impor- clinical decisions and health outcomes are improved [7, 28].
tant thing in engaging providers and reducing their resilience This finding was consistent with the results of the current study.
is to respond to their needs. If they feel that you, as a health In terms of access to information, Keely and Liddy’s study
system manager, are addressing their concerns, this results in reported that e-Referrals are promising to help address unfair
better cooperation … (P 1). “From the people’s point of view, access in a fragmented and inefficient system, and further de-
e-Referral is a limitation. Before establishing an electronic re- velopment of these services is needed [29]. E-health services
ferral system, it should be cultured in the community and their reduce the likelihood of unwanted and lost records and ensure
support should be obtained and efforts should be made to meet that patients’ health records and other vital information are
their expectations ...” (P 20). available as needed. Data exchange speed and information se-
curity were the other components in the e-Referral system in
Culturalization this study.
Concerning information security, Osman et al. emphasised
Today, with the implementation of the e-Referral system, that the problems related to privacy and security, lack of suf-
people should use electronic health services to go to medical ficient knowledge and ease of use of such technology, lack of
centres. Culturalisation should take place in organisations relat- acceptance of new technology, required costs, lack of human re-
ed to electronic referrals, service recipients and service provid- sources, lack of motivation, fear of change, convincing patients
ers. Implementing e-Referral may lead to resistance. Participant to accept the existing problems, many other problems in com-
 78 F. Tajari et al. • Key factors in the success of the electronic referral system

pensating for possible damages, etc. are among the obstacles ducted by Sikora et al., it was found that in healthcare systems,
to the use of e-Referrals [30]. The results of this study indicated little attention had been paid to the organisational culture of
that e-Referral systems should ensure that patient records are healthcare providers, which was very important for both man-
exchanged and stored via a login password or even electronic agement and service recipients [36]. Based on the results of the
biometric sensors. It should also ensure tracking of providers’ study, managers and health policymakers are often concerned
access to patient information in the system. According to the that the implementation of e-Referral may change existing prac-
study participants, laws and regulations should be planned tices, resulting in health workers resisting it. In a study, Juliani
at the national level, and all related organisations, as well as et al. indicated that we often focus on technology and forget
service providers, should participate in the development and the service providers who use the technology. One of the cost-
implementation phases. Naseriasl et al., in a study, found that effective solutions is training and advocacy of electronic referral
the common models of referral systems that have recently been system service providers so that we can use their capacity to
established in developed countries have important features strengthen the electronic referral system [34].
and capabilities, such as the use of referral guidelines, standard As stated by the respondents in this study, the payment sys-
tem for service providers should be such that service providers
referral forms and integration of referral systems in electronic
experience an increase in their motivation. Therefore, it is bet-
health records [31].
ter to design and improve the payment system with the help
The findings of the current study also indicated the signifi-
of specialists and physicians. Kiran et al. indicated that future
cance of developing laws and regulations, such as electronic re- changes in physicians’ pay should be evaluated prospectively
ferral laws, insurance laws, as well as judicial and legal laws. The to determine their impact on access. Solving the welfare prob-
results of a study by Mehtarpour and Tajvar also showed that lems of the health team will increase their motivation to provide
defining standard referral processes and establishing clinical quality services [37]. This finding was consistent with the results
guidelines by both recipients and service providers can help to of the present study.
implement effective strategies, which was consistent with our
study [32].
The results of the research also showed that the imple-
Conclusions
mentation of an e-Referral system needed the support of all The results of the current study showed that resource man-
individuals and organisations that were somehow involved in agement, IT management, culturalisation, development of rules
the implementation of this programme, the most important of and regulations, payment systems, as well as the satisfaction and
which were stakeholders, such as service providers, service re- advocacy of stakeholders, were important in the successful im-
cipients and organisations related to electronic referral service plementation of e-Referrals. This study provided rich information
providers are the main suppliers of electronic health informa- on key factors in the successful implementation of an electronic
tion, and thus they need to be encouraged to cooperate [33]. In referral system in the family physician programme (FPP) in Iran.
this regard, Juliani et al. also mentioned that we often focus on It is suggested that managers and policymakers of the health sys-
the technology and ignore that service providers plan and act tem use the results of the present study in planning, establishing
on e-Health [34]. and properly implementing the electronic referral system. It is
The results of the present study showed that culturalisation also recommended that the key factors be determined and in-
in the health system is effective at three levels: health policy- vestigated according to the prevailing local and cultural condi-
makers, providers and people as health recipients. This was tions and the facilities and equipment of each country.
in line with the study of Ghanei et al., who stated, “Although
taking care of people’s health can lead to improving people’s Acknowledgments. The authors are thankful to the Hospital
health, determining the cultural conditions plays a significant Administration Research Centre of the Islamic Azad University
role in promoting people’s health”. In this regard, the World of Sari for its technical and consistent support, as well as the
Health Organization (WHO) has used the concept of social de- Ministry of Health of Iran and its affiliated universities, chiefly
terminants of health [35]. On the other hand, in a study con- Golestan, in encouraging this project.

Source of funding: This work was funded from the authors’ own resources.
Conflicts of interest: The authors declare no conflicts of interest.

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Tables: 2
Family Medicine & Primary Care Review 2023; 25(1)

Figures: 1
References: 37

Received: 01.05.2022
Reviewed: 24.06.2022
Accepted: 10.10.2022

Address for correspondence:

Ghahraman Mahmoudi, PhD, Assoc. Prof.
Associate Professor of Hospital Administration Research Center
Sari Branch
Islamic Azad University
Sari
Iran
Tel.: +98 11 34445775
E-mail: [email protected]