Clinical information coordination | Clinical and psychosocial information referral | "Through this interwoven computer system, doctors can share information for patient referral" - PSE C 01 | "The reference and counter-reference sheet are ordered by the governing body of the Public System [...] with the identification card of the individual affiliated with the Social Security, the doctors can access the information" - DC 22 | "The Public System has the reference and counter-reference forms, and they are not the same for everyone [... ] they are filled out depending on each specialty or what the patient has" - PSII P 13 | "Doctors of outpatient consultation of the Public System do not make a referral, but rather patients with asthma are scheduled directly to the paediatric consultations and wait to be assigned an appointment" - PSI U 18 |
"The Public System still does not have a system as such, and we have to make do with two, four or five sheets that come to us" - PSE U 15 | "The Public System does not have a single, universal, online, interconnected medical history that can be consulted in any health establishment; therefore, it is not so agile" - D P 12 | "In the Social Security System, the computer system is a single network. All hospitals of this system handle that same information so that I can access it immediately through the system; the Public System does not have that network" - PSII P 10. | "The third-level paediatric hospitals do not handle the same medical history system, so the information is duplicated" - PSI U 20 |
"The form is generally not complete, and it is quickly done with four lines of the clinical chart, so it is insufficient information [... ]" - PSE U 15 | "Often, the referral from the first level does not come so explicit for many reasons. At the first level, they do not have the resources to do things in terms of diagnostic means" - D P 09 | "The doctor who makes the referral is not sufficiently meticulous in describing the data, or it could be that the level of quality of the exams is not very reliable, and you have to repeat them in a site that has better quality services" - PSII P 13 | "[...] the system that we use seems practical to me because it is all electronic. However, only 150 words can be entered, so you must put the essential things" - PSI U 18 |
"What could happen with this document is that it is not filled out when the crisis lasts a short time, so sometimes it is not filled out" - PSE P 19 | | "[...] the attitude of each doctor is unpredictable, but what is the obligation of any professional is if they receive information, to read and analyse it" - PSII U 05 | "Sometimes we write all the risk factors and all the situations, and at the hospital, they do not read the referral, so it is like when you arrive at the hospital, the specialist never reads the sheet" - PSI C 03 |
Use of the information | "Here [... ] we have [... ] an interwoven computer system so that doctors can verify or corroborate the data in the reference sheet with the system" - PSE C 01 "All exams are uploaded to the system [...]" - PSE C 01 | "If it is a professional in good standing will have to review, if he does not review it is already a failure of the professional, who does not use the available information, because the obligation is to put everything in the system" - D U 04 | "… the truth is that I go back and ask the mother all the questions again, I do not rely much on the reference document" - PSII P 13 | "There are specialist colleagues who do not read the referral sheet. They do not value the work that we do here, so there is no support" - PSI P 21 |
"I want to emphasize that we do not base ourselves on that little reference sheet alone. We expand all the information because there is not much data there" - PSE U 15 | "When a referral is received at the hospital level, always try to find out what is written by the referring staff. They try to see if there is anything that can advance the work" - D P 09 | "it is the obligation of any professional who receives information to read and analyse it. Some doctors do not do that, and it is a bias of the person, not a bias of the system" - PSII U 05 | "It becomes difficult for us to follow-up when we do not know what activities we should continue to do, and we have to start guessing based on the prescriptions that the patients have" - PSI U 20 |
Coordination of the clinical management | Follow-up of the patient | "Doctors perform follow-up, but only through outpatient medical consultation. Through emergency it cannot be performed" - PSE C 01 "If it is a child, the relative who is with the patient is responsible for taking the inter-consultation sheet to the statistics department to schedule an appointment" - PSE P 19 | "There are family doctors, but not in all health centres, nor in all operational units of the first level" - D P 09 "… in general, they usually come with their mother or if not with the maternal grandmother, they are the ones who take the patient to do the tests, ask for the appointment and that kind of things" - DC 22 | "If it is a patient who is at a low level, the information is brought by the parents, talking about paediatrics" - PSII U 05 "The patient who came from a rural area where the severe crisis could not be treated, came to the hospital, went through their clinical condition and must return home, but there is no health staff to go there" - PSII P 10 | "The follow-up depends on several things, on us as primary care, on the patient, and on the secondary level. So, when one of these three fails, there is no adequate follow-up, patients fail in adherence" - PSI C 03 "The person who attends, the person who attends during his crisis is the one who is in charge of following up" - PSI P 21 |
"There is seldom communication, only in case of emergencies. For example, we have a chat in which we indicate the keywords in the case of adults or some kind of emergency" - PSE U 16 | "the initiative is taken without having communicated, that is, changing the medication to a patient without having examined all the reasons why it was administered" - D U 04 | "Sometimes we find out over the phone who is on duty on the other side if someone is informed about the situation" - PSII P 13 | "There is no system where the doctor tells us what is happening and from that moment you will see the same doctor again in six months or a year" - PSI C 03 |
"There is no follow-up. We don't do anything else after we attend the crisis" - PSE U 15 | "in the third level, we do re-scheduling, we avoid < the patient going again > to his health centre" - DC 22 | "Many times, the number of patients exceeds the capabilities of the system" - PSII C 02 | "I do not know how specialists handle it because they do not send counter-references" - PSI P 13 |
Accessibility among levels | "Sometimes the first level of care fails in many things, in terms of what health care is related" PSE P 07 "What I have seen is that they always value the attention of a private clinic, more than the attention in an entity whether it is Social Security or Public" - PSE C 01 | "In the national health system, which would imply the public network and the complementary private network, does not comply for matters such as asthma in an appropriate way" - D U 04 "Getting an appointment at a health centre is almost like trying to reach the moon" - D P 12 | "I generally don't return patients to primary care due to bad experiences, they come back or their treatment is cut off due to lack of knowledge or left for 3–4 years" PSII C 02 "In private practice, there is no time limit, [...], what I always strive for is that the patient is attended to and receives good care" PSII U 05 | "Time is too long for patients to schedule appointments" PSI C 03 "Sometimes we do not have means of transportation. However, we have the support of ECU911. They are the ones who are contacted so that they can activate an ambulance for the transfer" PSI U 20 |
Care consistency (or coherence) | "Sometimes different doctors or rural doctors arrive, who due to their lack of experience does not handle this pathology or at the time when the patient arrives, they can be confused with another type of pathology" - PSE P 07 "If the protocol were ideal, it would know what corresponds and what does not correspond to each level" - PSE U 16 | "Each doctor in each institution handles this type of patient in a different way, so there may be a deficit in a general guideline for treating this type of patient" - D P 09 "To be able to call it an integrated health network, I think we also lack much coordination between parts (we are very jealous). For example, the Public Health and Social Security parts cover two large masses that should be one" - DC 22. | "The majority of patients shouldn't even be at a specialty level. The problem is that the primary care physician or paediatrician doesn't try to reach a diagnosis" PSII C 02 "As specialists, it makes us a bit nervous about releasing these patients because after having them under the best control, when we send them to primary care, they come back with a relapse or with a hospitalization" PSII P 10 | "The patient sees the hospital specialist as "the hospital specialist", so if the hospital specialist does not tell the patient what we are saying is a valid instruction, the patient often does not adhere to the instructions" PSI C 03 "I don't know how specialists manage because they don't send against references […]in general, counter references are not handled well" PSI P 23 |
"We, in what the emergency area concerns, become a short stay, it varies from 4 hours to 8 hours, the maximum time a patient stays" - PSE C 01 "I think it's also a matter of access because many children who come to me come without a clear established treatment" - PSE U 15 | "A deficit in the way asthma is approached at the first level, a deficit of knowledge or lack of knowledge of professionals at the first level of care" - D P 09 "Their return is still less frequent, so that is a problem. Someone says how can they send someone to a lower-level site, but it is obvious, they must send them to a lower-level site for daily management" - D U 04 | "The management of asthma in rural areas, and marginal urban areas where there is a lack of expertise, is a concern for me, and it is truly a complicated problem." PSII U 06 “I always joke around with my colleagues and say they nebulize even diarrhoea. A child comes with diarrhoea, they listen and find they have mucus, and they give them a nebulization treatment, and that has happened at an institution here" PSII C 02 | "We are supposed to speak the same language, the limitation is that there is an underestimation and they say, "it is primary level, there is not enough knowledge", so from the second level they send other treatments" PSI C 03 "In my experience, I have seen that management is somewhat deficient in primary care because they only focus on treating asthmatic attacks" PSI P 23 |
"They don't attend to them [children with asthma] because they don't want to deal with the complexity of children because children are more complicated patients and require more technique and practice. If there is no paediatrician available, they prefer not to take responsibility and refer the patient elsewhere" - PSE U 16 | "It is not the lack of communication itself. It is the lack of optimized management in the referral and counter-referral protocol" - D U 04 "Inadequate referrals are reported from the hospital, perhaps references that were not needed" - D P 09 | "Again, it is the number of patients, but the majority of patients shouldn't even be at a specialty level. The problem is that the primary care physician or paediatrician doesn't try to reach a diagnosis" - PSII C 02 | "Since the system is often saturated, what happens is that these patients have already waited a long time and then we must update the tests again" PSI U 17 |
Administrative coordination | Administrative circuits | "There are many patients who do not attend the first level of care, as the first level requires a patient or family member to call for an appointment and there is no estimated time for these appointments as the shifts at the first level are congested." - PSE P 19 | "It is a system that is not efficient when it comes to reserving a consultation or appointment because remember that there should not only be a reference and coreference, but here it is not done. It seems inefficient to me for all of Ecuador and the people who are not suffering for an appointment not only at the public health level but also at the Social Security level" - DP 12 | "The problem appears many times in the times in which the specialist or doctor who has to see it will see it in a prolonged matter, and that causes the parents to be upset, and also many times parents take other alternatives and that makes them fall into places where they shouldn't be" - PSII C 02 | "The limitation, as I said, is in the shifts in the hospital, the appointments are postponed a lot. Therefore, we have an average of two months waiting time minimum for an appointment" PSI C 03. |