Using Hospital Claim Data to Develop Referral Decision Support Systems: Improving Patient Flow from The Primary Care

Abstract The decision to make a referral for a primary physician is influenced by several factors such as the need for specialist consultation and requesting support for diagnosis or disease management using advanced equipment. Unfortunately, primary care physicians are faced with a number of hospitals that have different resources. This study aims to improve the quality of referral services by facilitating primary care physicians in determining the right referral hospital or specialty care. Prototyping method was used to extend rule-reasoning decision support in an electronic referral system where hospital coordinates and real-time availability of bed exist. The research was conducted in DI Yogyakarta province, Indonesia. Appropriate referral hospital was inferred based on the presence of differential diagnosis and or required procedure. The history of medical diagnosis and procedures from hospital claim data was used as knowledge-based that connect hospital master data. IF ... AND (OR) ... THEN rule-reasoning was used to recommend referral hospitals based on a differential diagnosis and or required medical procedure determined by a primary care physician in the electronic referral system. To narrow down the referral hospitals, the Google Maps API was used to estimate the distance from primary health facilities to several available hospital options. Information on the availability of beds was also visualized for preference in determining the choice of a referral hospital. A decision support system can help primary care physicians to find the right referral hospital or specialty care for a desired patient before making a referral to a higher level of health facility.