Informatics in Medicine Unlocked 17 (2019) 100263

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Informatics in Medicine Unlocked

journal homepage: http://www.elsevier.com/locate/imu

The Information System/Information Technology (IS/IT) practices in the

Indonesia health referral system
Putu Wuri Handayani a, *, Ave Adriana Pinem a, Fatimah Azzahro a, Achmad Nizar Hidayanto a,
Dumilah Ayuningtyas b
a
Faculty of Computer Science, University of Indonesia, Indonesia
b
Faculty of Public Health, University of Indonesia, Indonesia

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: The purpose of this study is to understand how Information System/Information Technology (IS/IT) is
Health referral used to support the health referral system in Indonesia.
Health referral information system Method: This study uses a qualitative approach, with case studies at the Ministry of Health of the Republic of
Primary care
Indonesia (MOH) as the sector regulator, the Social Security Agency for Health (BPJS-K) as the Indonesian
Hospitals
government body in organizing a health insurance program for all Indonesian citizens, and hospitals as the health
Indonesia
providers in the DKI Jakarta Province. The 33 respondents involved in this study are policy makers, medical
personnel who use the health referral information system, such as doctors, nurses and administrative staff, and
application developers who develop and deploy the applications for health referral.
Results: The study reveals that most of the health facilities and providers in the DKI Jakarta Province have used
health referral information systems, even if the system is not fully integrated or does not have a complete set of
features. All of the relevant stakeholders should be able to manage the technical and non-technical problems in
the health referral information system. Strong integration and well-structured planning in IS/IT application could
reduce the queuing processes in health facilities.
Conclusions: Based on this study, MOH as the health regulator should draft regulation(s) that defines the health
data dictionary as a reference for interface between health referral applications developed by each health facility
or regional government. In addition, the chairperson of health facilities providers should have a strong leadership
commitment and good coordination with other health facilities in performing the usage of health referral in­
formation systems.

1. Introduction
The Indonesian Government has launched a National Health Insur­
ance (NHI) health program in which all citizens are facilitated in
obtaining healthcare access. NHI is one platform for the implementation
and development of health efforts within the National Health System
(NHS). As part of the NHS implementation plan, a division of tasks
among health facilities, or a so-called referral system, is required to
obtain high-quality health services that are both effective and efficient.
According to the Ministry of Health of the Republic of Indonesia (MOH),
both effectiveness and efficiency can be achieved if a referral system is
organized with the aim of providing quality health services; this way,
service goals can be achieved with minimal cost [1,2,6]. Of particular
importance are reducing the waiting time in the referral process and
reducing the number of unnecessary transfers, because the required
service can be handled by the original health services facility, either
with the help of available cutting-edge or low-cost technology.
To date, MOH only regulates the health referral systems of individual
health services, as set out in Law No. 40 of 2004 on Guarantee System
National Social and implementing Regulation of MOH Number 001 of
2012 regarding Individual Health Service Referral Systems (MOH
Regulation 001/2012). Based on MOH Regulation 001/2012, the health
referral system is defined as a health service arrangement that regulates
the delegation of duties and responsibilities of health services on a
reciprocal basis, either vertical or horizontal. Based on this definition,
the health referral system is required for all patients who participate in

* Corresponding author. Faculty of Computer Science, Jalan Kampus UI, Depok, West Java, 16424, Universitas Indonesia, Indonesia.
E-mail addresses: putu.wuri@cs.ui.ac.id (P.W. Handayani), ave.pinem@cs.ui.ac.id (A.A. Pinem), azzahro.fatimah@cs.ui.ac.id (F. Azzahro), nizar@cs.ui.ac.id
(A.N. Hidayanto), dumilah@gmail.com (D. Ayuningtyas).

https://doi.org/10.1016/j.imu.2019.100263
Received 26 August 2019; Received in revised form 30 October 2019; Accepted 31 October 2019
Available online 12 November 2019
2352-9148/© 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
P.W. Handayani et al.
health insurance or social health insurance and or receive care from any
healthcare provider. Starting from January 1, 2014, the Social Security
Agency for Health (BPJS-K) was appointed as the sole implementing
body established by the government to organize a health insurance
program for all Indonesian citizens.
To date, the current referral system in Indonesia is still ineffective
because of the visible accumulation of patients in the hospitals compare
to first-level health facilities. Most of the patients do not seek treatment
within the first-level health facilities due to management of patient file
administration, which is still done manually. The issues could be
handled properly if each health facility were to be using an integrated
Information System/Information Technology (IS/IT), so that the health
services could be provided to the patient optimally. By using IS/IT, in­
tegrated with health facilities’ information systems (e.g., a community
health center system, hospital information system, or referral system
application [P-Care] from BPJS-K), healthcare facilities could more
quickly and readily access patient medical records, ensuring that the
decision to refer a patient could be made quickly, and adjusted to the
availability of personnel and medical equipment at the referral health­
care facilities.
Until now, there has been limited research examining the health
referral systems and the utilization of IS/IT to support these systems.
This study has as a purpose, to understand how the IS/IT is utilized to
support the health referral system in Indonesia. Bossyns and Lerberghere
viewed a non-optimal health referral system in Nigeria, but focused
more on the interaction between health workers and patients, and
whether these interactions can be an impediment in running a tiered
referral system [3]. A study by Akande examined the health referral
system in Nigeria, showing that highly skilled workers and adequate
equipment are needed for the implementation of the referral system [4].
Pembe et al. evaluated the effectiveness of the maternal referral system
in the rural district of Rufiji in Tanzania [5]. Health referral system
research conducted in Indonesia has been limited and still focuses on the
use of health referral systems in hospitals; however, no studies have
been undertaken at first level health facilities (FKTP). Furthermore, the
Indonesian health system is unique and has limitations in terms of the
facilities and health personnel availability. It also has a decentralized
and tiered health system; therefore, the utilization of IS/IT has been one
of the health reform initiatives in Indonesia, although the implementa­
tion is not yet optimal. The research question therefore arose: how is
IS/IT used in health facilities to support the health referral system in
Indonesia?
The remainder of this paper is organized as follows: Section 2 re­
views the existing literature, and Section 3 explains the conceptual
model. Section 4 describes the research methodology. The results and
discussion of this research are subsequently presented in Section 5 and
Section 6, respectively. Section 7 explores the implications of this
research, and the final section, Section 8, discusses conclusions and
recommendations for future work related to this research.
2. Literature review: Indonesia health referral system regulatory
framework
The health referral system in Indonesia is subject to regulations is­
sued by the government. Based on MOH Regulation 001/2012, the
health referral system is defined as a health service arrangement that
regulates the delegation of duties and responsibilities of health services
on a reciprocal basis, either vertical or horizontal, which must be carried
out by those who participate in health insurance or social health in­
surance and by all health facilities. The general objective of individual
healthcare referral systems is the execution of individual health referral
procedures, following the quality and patient safety standards of the
reference criteria, at individual health service facilities of all levels in
Indonesia [7].
According to the Guidelines of the National Referral System, to be
able to establish a personal referral system in a good, steady, and
2
Informatics in Medicine Unlocked 17 (2019) 100263
sustainable manner, the mapping of referral areas in each level of the
referral system and national reference system must first occur, with
reference system units included therein [7]. The task of mapping the
referral system at the regency/municipal level is the responsibility of the
Regional Health Office, BPJS-K, and its network (i.e., branch offices),
while the task of mapping the referral system at the provincial and
higher levels is assigned to the Provincial Health Office and MOH, and
especially the Directorate of Referral Health Development [7]. In the
DKI Jakarta Province, based on the Regulation of the Governor of DKI
Jakarta No. 189 of 2015, the regulation is formulated as the legal basis
and reference for health service facilities in carrying out the regionali­
zation of health referral systems in the relevant region. The objective of
this regulation is to develop the regionalization of a tiered referral sys­
tem, to improve the quality and reach of referral health services in
hospitals, and to even out the distribution of referral health services.
Based on the Practical Guide to the Tiered Referral System issued by
MOH, the referral system in Indonesia has been arranged in a tiered
form, comprised of first-, second-, and third-level health services; as
such, its application does not stand alone but is part of an interconnected
system [[6]8]. Table 1 describes the classification of each healthcare
facility.
Further, based on MOH Decree No. 28 of 2014 regarding Guidelines
for Implementation of National Health Insurance Program, health fa­
cilities are divided into two facility levels: First Level Health Facility
(FKTP) and Advanced Level Health Facility (FKRTL). FKTP includes
primary healthcare centers (Puskesmas or Pusat Kesehatan Masyarakat),
physician private practices, dentists, primary or equivalent clinics, and
class D hospitals or equivalents. FKRTL includes primary or equivalent
clinics, general hospitals, and special hospitals. FKRTL is distinguished
into second-level health facilities (healthcare facilities generally located
in the Provincial Region, such as a provincial general hospital) and
third-level health facilities (healthcare facilities generally located in the
capital city, such as a central general hospital).
3. Methods
This research is a qualitative study (case study research) using in­
terviews to collect data. The research phase starts from identifying
problems, literature review, sample construction, instrument prepara­
tion, conducting face-to-face interviews, and analyzing the interview
data. The bulk of this research was performed in health facilities in the
North Jakarta region of DKI Jakarta Province, because the health
referral system processes from FKTP to FKRTL have been continuously
conducted in the North Jakarta region compared to other regions in the
DKI Jakarta Province. The research is performed based on a preliminary
interview with the Head of the Data and Information Section of DKI
Jakarta Province. After the preliminary interview, we developed in­
struments for structured interview to the respondents, as suggested by
the Head of the Data and Information Section of DKI Jakarta Province.
Interviews were performed using the same interview questions with
health referral system regulators, as well as users and managers of the
health referral applications, with 33 people interviewed in total. The
person being interviewed is selected based on the direction from the
relevant head of government institutions on the basis of their expertise,
knowledge, and scope of their works or their position which is most
relevant to this study. The list of respondents involved in describing the
health referral system is set out in Table 2. Data was collected from
February 16, 2017 to May 4, 2018 (16 months).
Further, based on the health profile of DKI Jakarta Province in 2014,
the hospital bed ratio to 1000 residents in DKI Jakarta was 2:3, means
that there were 2 beds per 3000 residents, which is above the ratio for
national coverage (1:7). The highest ratio was in Central Jakarta region
(6:7) while the lowest ratio is in Kepulauan Seribu (Thousand Island)
region of (0:6). Based on the data, the health referral system process has
been fully conducted in the North Jakarta region and this study selected
four FKTPs and two FKRTLs in handling many referral patients. To
P.W. Handayani et al. Informatics in Medicine Unlocked 17 (2019) 100263

Table 1
Healthcare Facility Classification [7].
Referral Level Duties of Healthcare Facilities Healthcare Facilities Responsible for Monitoring
and Evaluation

First-level Able to provide first-rate medical services performed by a doctor/ 1. Community health centers 1. Head of Regency/
healthcare dentist and specifically able to provide psychological, neonatal, and 2. Primary clinics (government and private) Municipality Health Office
facilities maternal services, in certain conditions assisted by a midwife. 3. Private practices of doctors/dentists 2. Professional organization
4. Primary hospitals of regency/municipality
branch
Second-level Able to provide specialist personal health services. 1. Class D or C hospitals 1. Head of Provincial Health
healthcare 2. Non-educational class B hospitals, government- Office
facilities owned hospitals, and army forces/police/state/ 2. Provincial branch
privately owned hospitals professional organization
Third-level Able to provide sub-specialist health care. 1. Class B education/class A hospital in the 1. Directorate of Referral
healthcare province Health Promotion
facilities 2. Class A hospitals (general referrals/general 2. Directorate General of
national in cities) Health Efforts
3. Professional organizations
4. Educational institutions

obtain a comprehensive knowledge of the health referral system, this
study also included interviews with the health regulators (i.e., MOH)
and referral application developers who have successfully deployed the
health referral applications in Indonesia, to understand the lessons
learned by the developers when they deployed the health referral ap­
plications. The duration of interview was between 30 min and 1 h for
each interviewee, and there were one to two iterations when conducting
interviews in each case study, to enable researchers to discover and
discuss all information related to the processes of the health referral
system. The results of the interview were recorded with an audio
recorder, transcribed and coded by the researcher for each important
point throughout the interview. In relation to the ethics of this study, we
have obtained approval from MOH (the Directorate of Referral Health
Services and the Data and Information Center), BPJS-K, Provincial
Health Office of DKI Jakarta Provinces, relevant health care centers,
hospitals and interviewees that the result from this study will be pub­
lished. In addition, all participants have provided their consent to be
interviewed for this study and approved that the results of interview will
be published in a journal or publication. Table 3 shows the interview key
point of questions.
We used content analysis to organize and elicit meaning of interview
data and draw conclusion from it. Content analysis is a widely used
qualitative research method for studying documents and communica­
tion objects, which might include texts in various formats, audio, video
or picture [12]. The results of the analysis are grouped with the results,
namely (1) the actual processes carried out in the health referral system,
(2) the support of IS/IT on the health referral system and (3) the prob­
lems that occur in the health referral system.
4. Results
Referral flow consists of vertical referrals, back referrals, and hori­
zontal referrals between hospitals in the same class or between units in
one hospital (e.g., referring patients from emergency departments to
inpatient units). Vertical referrals are made from the health facility of a
lower class to a health facility that has a class at least one level higher
than that of the referrer health facility. In contrast to vertical referrals,
back referrals are done from a health facility of a higher class to one of a
lower class. Finally, horizontal referrals occur between units in one
hospital and between hospitals of the same class. Based on the Head of
Medical Services of Tugu Koja General Hospital, all referral flows are
performed by sending patient identity data, the reason for the referral,
the follow-up treatment, and the medical resume.
The Head of Public Relations of BPJS-K said that “specifically for
emergency referrals, a tiered referral mechanism is not necessary and that the
selection of hospitals for the referred patient is adjusted according to the
patient’s level of severity, the appropriate facilities needed to provide care,
and the health personnel available at each hospital”. In other words, for
emergency referrals, administrative and/or geographical boundaries
can be ignored because the important thing is that the patient receives
prompt and appropriate care within a very decisive period (i.e., the
“golden period”). According to the Director of Dr. Wahidin Sudir­
ohusodo Hospital and the Head of Medical Services of Tugu Koja General
Hospitals, communication in emergency referrals is very important;
because the referral process must begin and end with communication.
Emergency referrals are performed by transferring patient identity data,
diagnoses, and necessary actions that need to be performed for the
relevant patient.
To accelerate the health referral service process, MOH has developed
three referral applications, BPJS-K has developed nine referral applica­
tions, and the Provincial Health Office of DKI Jakarta has developed one
referral application. In general, the features required for the health
referral system consist of the following:
1. Patient, medical personnel and health facility profile information as
well as patient medical resume;
2. Schedule information of physician polyclinic service in hospital by
date, day, and hour;
3. Room availability information;
4. Reservation/appointment booking service of polyclinic doctor or
booking room in hospital;
5. Confirmation of patient referral patients at the hospital; and
6. Reports related to patient referrals.
Based on interviews with all the respondents, there are still dupli­
cation functions performed in more than one application. For example,
both the Online Referral Service System (SPRO) and Integrated Referral
System (SISRUTE) can be used to perform scheduling and patient
registration to the intended outpatient installations. Then, integration
methods performed between the BPJS-K’s applications are done using
web services. Health facilities in Indonesia use different health appli­
cations, resulting in a complex integration mechanism. The complica­
tion arises because there is no standard reference that can be used, as
well as strong coordination between the central regulator and the local
facilities, and as such, there is no SI/IT plan in place to allow for synergy
between the healthcare regulators and providers. The lack of coordi­
nation also makes it difficult to achieve a standardization in health data
between the various parties. In addition to the complexity of integration
between applications, each health facility requires IT staff who can
support the maintenance of these applications. However, many health
facilities do not have permanent IT staff due to limited budget. Table 4
explains the summary of results.
Based on input from all respondents and analyzing the results, the
following list of actions need to be made a priority to resolve all

3
P.W. Handayani et al.
Table 2
Respondent demographics.
No. Name of Health Facility Position of Respondent
1. Directorate of Referral Section Head of Referral
Health Services with the Service Management
MOH Staff of Referral Service
Management
Staff Section of Planning and
Development of Medical
Services
Referral Application
Coordinator at the Referral
Service Information Center
Head of Sub Directorate of
Integrated Emergency
Services
2. Data and Information Head of Information System
Center of the MOH Development Division
Data Center and Information
Center staff
3. BPJS-K Head of Public Relations
Department
Staff of Information
Management and
Documentation Officer
4. Si Jari Emas and Si Jari Emas Application
SMSBunda Application Developer
Developer SMSBunda Business
Development Director
5. Health Office of DKI Section Head of FKRTL Health
Jakarta Province Health Services Division
Services Division Section Head of FKTP Health
Services Division
Head of Data and Information
Section
IT staff
6. North Jakarta Health Head of Health Services
Office Section
Staff of Health Services
Section
7. Koja Primary Health Online referral staff
Care Center General practitioners of
polyclinics who actively use
referral applications
8. Cilincing Primary Health Head of Individual Services
Care Center Division
IT Analyst
9. Kelapa Gading Primary Referral Operator Staff
Health Care Center Elderly Polyclinic Doctor
(person in charge of Referral
Application)
10. Penjaringan Primary Head of Individual Services
Health Care Center Division
Reporting and Procurement
Section staff
BPJS-K Application Operator
11. Tugu Koja General Head of Implementation Unit
Hospital of Emergency and Outpatient
Head of Education and
Training Section
Head of Medical Services
12. Koja Public Hospital Head of Hospital Information
System
Director of Koja Public
Hospital
13. Dr. Wahidin Administration and Reporting
Sudirohusodo Public Staff of Hospital Information
Hospital System Installation
Director
problems and achieve successful execution of health referral systems:
� Relevant regulation(s) for the implementation of health referral
systems (e.g., the regionalization of referral regions, the creation of
clinical pathways, the development of a referral system data
Informatics in Medicine Unlocked 17 (2019) 100263
Table 3
Interview key point of questions.
Number of No Respondents Key Point of Questions
Respondents
1. Health regulators (MOH, BPJS-K, � Regulation used as a basis for
1 Provincial Health Office of DKI implementing health referral
Jakarta Province, North Jakarta systems in Indonesia
2 Health Office) � Supports provided by health
regulators to health facilities in
1 running referral systems (e.g., the
support of referral applications,
human resources, and so on)
1 2. Health facilities (Kelapa Gading � Requirements needed to run a
Primary Health Care Center, Koja health referral system and IS/IT to
Primary Health Care Center, support the health referral system
1 Cilincing Primary Health Care (e.g., the applications used, users
Center, Penjaringan Primary Health using the health referral system,
Care Center, Tugu Koja General integration of the referral
2 Hospital, Koja Public Hospital, Dr. application with other related
Wahidin Sudirohusodo Public application, and so on)
Hospital) � Problems faced in the health
referral system
2 3. Health referral application � Main features developed in the
developers (Si Jari Emas and referral application
SMSBunda Application Developer) � Issues occurred in the health
referral application
2
Table 4
Summary of results.
4
Analysis Results
Actual health referral system � Vertical referrals, back referrals, and horizontal
activities in health facilities referrals are conducted in health facilities
Health referral system strength All relevant stakeholders have already used the
online health referral information system
Health referral system � duplication functions performed in more than
2 weakness one application
� complex integration mechanism due to the
different referral applications used in health
facilities
2 � lack of IT resources in the health facilities
dictionary). In addition to health facilities, the referral network also
2
needs to be connected to the ambulance system and blood bank.
� Strong leadership from regulators and health facilities.
2 � The development of applications tailored to user needs that can be
easily integrated with other related applications.
� The involvement of local stakeholders in various ways in the devel­
3
opment of an integrated, comprehensive referral system. The
engagement of end users in the design and the systematic use of their
feedback to revise the system and improve the user experience, as
this is helpful in ensuring that the features of the system meet their
needs.
2
� Determination of Service Level Agreements (SLA) for referral appli­
cations that must be mutually agreed upon between regulators and
health service facilities to ensure standardization in providing
services.
2
� An understanding of participant and health services facility re­
quirements in the tiered health referral system as well as patient
education for the re-control of chronic diseases, which can be used
2 for referral.
� The readiness of supporting facilities and infrastructure, such as
Internet communication networks and integrated health
applications.
� The availability of online communication and data networks in
FKTPs as well as in FKRTLs and the smooth access to communication
and data networks as the foundation of the online health referral
systems.
� The commitment and discipline of FKTPs and FKRTLs in conducting
service entries in the health referral application and carrying out all
4
P.W. Handayani et al.
of the provisions and regulations set by the health referral system
regulator.
� Coordination with regency health offices and related health facilities
in improving the availability of communication and data networks in
non-sustainable areas or no jurisdictions.
� Conducting IT governance in each health facility.
� The readiness of human resources personnel who know and under­
stand IT/IS in helping with the development and support of health
referral applications.
5. Discussion
According to Gillies et al., integrated health systems are widely
considered to provide superior performance in terms of quality and
safety because of effective communication and standardized protocols,
although these outcomes have not been fully demonstrated [10]. Health
referral systems must also be developed in an integrated manner; thus,
the operation of an integrated health system requires leadership with
vision as well as an organizational culture that is congruent with the
vision [9,11,12]. Developing integrated health referral systems is time
consuming, complex, and costly; therefore, health regulators should
have a clear IS/IT strategic plan and standards so that health facilities
can have access to standard data, eliminating duplicate applications that
have the same functionalities. For example, SPRO and SISRUTE,
developed by the Health Office of DKI Jakarta Province and MOH,
respectively, have a similar functionality for referring patients that
could be homogenized into a single application.
To date, in Indonesia, there is an awareness within regulator and
health facilities about using IS/IT to support the health referral system,
and there is not such a reliance on highly skilled workers and equipment
as there is in Nigeria [4]. The execution of a health referral system re­
quires the Puskesmas Information System (PIS) for FKTPs and the Hos­
pital Information System (HIS) for FKRTLs as a backend support to
health referral applications. The PIS and HIS must be integrated so they
can facilitate the exchange of patient data. These conditions can bring
health facilities closer to the community as they improve the account­
ability of the referral data. However, because there is no comprehensive
coordination between the regulators and implementers of the health
referral system, there are still many duplicate functions in various health
applications, increasing the complexity of the integration between the
health applications in each health facility. To date, MOH also does not
have a data dictionary related to the development of PIS/HIS and health
referral applications, so there is no standard data that can be excluded
from health referral applications that have been developed to date.
These conditions make it difficult to integrate data between health fa­
cilities and regulators.
Furthermore, the health referral system in Indonesia includes verti­
cal and horizontal patient references (i.e., internal and external), spec­
imen referrals, and expert referrals [7]. Currently, however, based on
interviews with the Head of the Referral Health Service Section and the
Directorate of Referred Health Services with the MOH, the development
of health referral applications still focuses only on individual referral
systems. Moreover, it has not yet been implemented for community
health business referrals. In the future, a health referral system should be
developed in an automated manner based on severity levels, and in a
manner that is integrated between services and health facilities. The
addition of features that can cover the entire health referral process is
indispensable for the successful execution of a health referral system.
Issues have arisen for implementing the health referral system in the
certain areas of Indonesia because such areas do not have Internet access
or electricity yet. Therefore, regulators and health facilities need to
conduct comprehensive planning related to the health referral systems
by not only providing access to online health referral systems but also by
developing methods of conducting referrals offline. In addition, based
on interviews with the FKTP Section Head of the Health Services Divi­
sion at the Provincial Health Office of DKI Jakarta Province, another
5
Informatics in Medicine Unlocked 17 (2019) 100263
issue in the current health referral system is that regionalization is too
rigid and hospital classification in each regency has been incomplete, so
that referrals are highly dependent on doctor diagnoses.
6. Implications
The results of this study could theoretically enrich previous research
in providing knowledge related to the health referral systems in devel­
oping countries with limited health personnel and health infrastructure.
This study also determined the factors required for the success of health
referral systems. This study has implications for regulators (i.e., MOH,
Health Office and BPJS-K) where regulators must prepare relevant
regulation(s) regarding IS/IT for supporting the health referral system.
Health facilities also need to develop applications tailored to the needs
of users that can be easily integrated with other related applications,
need to ensure the readiness of supporting facilities and infrastructure,
and need IT governance in each health facility. In addition, patients also
need to have awareness of the tiered health referral system.
7. Conclusion and future work
This research discusses the use of IS/IT in support of health referral
systems. To support the health referrals system in Indonesia, health fa­
cilities may develop their own referral health applications, even though
regulators have also developed reference applications that can be used
by health facilities. However, because such applications cannot be in­
tegrated with other related applications, no unified health referral sys­
tem has been created to accommodate all of the needs in the health
referral process. In addition, there are some health facilities that resist
using applications, and instead refer manually even though they already
have a system. Using IS/IT can facilitate better access to and sharing of
patient information between health facilities to accelerate services. In
addition to technical factors in the application, non-technical factors are
also very influential to the success of the health referral system. The
limitation of this research is that it only focused on the North Jakarta
region, where the health referral system has been continuously applied
with support from IS/IT in Indonesia. The results of this study can be
used to examine the factors related to the acceptance of health referral
systems and related analysis of success factors in the utilization of mo­
bile applications to support the health referral process. In addition, this
research can be used as a reference in developing health referral appli­
cations that can meet the overall needs of the health referral process.
Summary points
Summary of previous studies:
� Most of the research regarding health referral system still focus on
the referral systems in hospitals
� To date, there has been limited research examining the imple­
mentation of health referral information systems and the utilization
of IS/IT to support the health referral systems
Summary of this study:
� This study aims to analyze the practices of IS/IT in the health referral
system in primary care and hospitals in Indonesia
� This study revealed that most health facilities have implemented the
health referral information system
� Stakeholders should manage the technical and non-technical issues
� Using the implementation of IS/IT, health facilities could reduce the
patient queuing processes
Ethical statement
Regarding the ethics of this study, we have obtained approval from
P.W. Handayani et al.
the following individuals and facilities:
� MOH: allowed to conduct interviews with the Directorate of Referral
Health Services on February 16, 2017 and the Data and Information
Center on May 9, 2017.
� BPJS-K: consent given in letter number 3184/VIII.2/0317, dated
March 14, 2017.
� Provincial Health Office of DKI Jakarta: consent from the Head of
Health Resources Section given in letter number 703/SDK/VI/2017
and letter number 500/SAK/V/2017.
� North Jakarta Health Office and Kelapa Gading Primary Health Care
Center: issued a license to perform an interview from the One Stop
Service Integrated Service (PTSP) of North Jakarta, reference num­
ber 78/16.1/31.72/-1.862.9/2017.
� Koja Primary Health Care Center: given consent from the PTSP of
North Jakarta Municipality, reference number 109/16.1/31.72/-
1.862.9/2017.
� Cilincing Primary Health Care Center: given consent from the PTSP
of North Jakarta Municipality, reference number 110/16.1/31.72/-
1.862.9/2017.
� Penjaringan Primary Health Care Center: given consent from the
PTSP of North Jakarta Municipality, reference number 113/16.1/
31.72/-1.862.9/2017.
� Tugu Koja General Hospital: given consent from the PTSP of North
Jakarta Municipality, reference number 74/16.1/31.72/-1.862.9/
2017.
� Koja Public Hospital: given consent from the PTSP of North Jakarta
Municipality, reference number 75/16.1/31.72/-1.862.9/2017.
� Dr. Wahidin Sudirohusodo Public Hospital: given consent from the
PTSP of South Sulawesi Municipality, reference number 4524/S.02/
PTSP/2018.
Declaration of competing interest
The authors declare that they have no potential conflicts of interest.
Informatics in Medicine Unlocked 17 (2019) 100263
Acknowledgements
We want to convey our gratitude to the support of Faculty of Com­
puter Science, Universitas Indonesia through the internal publication
grant.
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