The complainant informed the Ombudsman about the termination of validity of the referral the day before the specified examination. The Ombudsman found that the reason lies in communication problems between the contractor and the central system, more specifically with external software houses that take care of the contractor's information system. The Ombudsman expects the Ministry of Health and the National Public Health Institute to deal with the problems as soon as possible and inform him of the result. He proposed to both of them to establish communication with health care providers who are having problems with the expiration of referrals, and in cooperation with them to find solutions in the shortest possible time that will be suitable for both patients and health care providers.

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A complainant who claimed that he had received a notification that his referral had been deleted one day before the scheduled examination turned to the Human Rights Ombudsman of the Republic of Slovenia (Ombudsman). On the same day, he obtained a new referral from his personal doctor. He turned to the Ministry of Health (MZ) for an explanation about the deletion, which explained to him that his referral was closed as unused and that it appeared in the eNaročanje system as if he had not attended his last examination (prior to the control examination). The complainant proved his attendance at the last checkup with a certificate of completion of the checkup at the University Clinical Centre of Ljubljana (UKC LJ).

The Ombudsman is aware of patient problems due to invalid referrals. He turned to the National Public Health Institute (NIJZ) and UKC LJ for clarifications. The NIJZ explained that in the case of the complainant, the central eNaročanje system did not receive any information about the processing from the contractor's local information system. In accordance with the legal provisions, the unexecuted order was cancelled, and the complainant's referral was closed. On 10/10/2022, the eNaročanje service was reactivated after being shut down due to the pandemic. In accordance with Paragraph 3 of Article 15b of the Patients’ Rights Act (ZPacP), the service operates in the following manner: if there is an exact appointment (the patient has a specific day and time of the examination) and the central eNaročanje system does not receive information about the realisation, cancellation, or reordering within 35 days after the appointment, and the patient has not excused her or himself, the said order, which was not realised, is cancelled. All remaining orders on the referral and the referral itself are also cancelled. The cancellation of unrealised appointments, for which the patient did not show up and did not excuse him or herself after 30 days, completion of the related referrals and cancellation of the remaining appointments are carried out daily.

The NIJZ explained that it is the responsibility of health care providers to complete appointments appropriately and they have three options:

• the patient attended a certain appointment, which is marked as completed,
• the patient did not attend the appointment and excused themselves, the appointment is cancelled with one of the reasons for cancellation,
• the patient did not attend the appointment and excused themselves, the patient is assigned a new date.

If the contractor implements one of the three measures mentioned above, the appointment will not be cancelled and the referral will not be completed by the central eNaročanje system. From January 2023, health care providers have a tool available in the local information system that shows them all unrealized orders in the central system and which will be cancelled in accordance with the stated procedure, if the central system does not receive any information regarding the date of performance.

UKC LJ informed us that the service was carried out with the first indent – the patient attended the examination, which is marked as carried out. UKC LJ attached a screenshot, which proves their statement. UKC LJ also stated that the information about the execution of the examination is visible only in the local system, but not in the central system. That is why problems are thought to occur. UKC LJ informed the MZ about this in writing. UKC LJ responded to the statements of the NIJZ, which states that from January 2023 contractors have a tool available in the local system that shows all orders for which realisation is missing in the central system, and which will be cancelled if the central system does not receive information about the execution of the examination. UKC LJ does not agree with the NIJZ’s statement. They have been contacting the NIJZ since 25/11/2022, asking monthly for information on orders that are scheduled for cancellation. UKC LJ stated that after the reactivation of the service in the eNaročanje system, UKC LJ began to notice unjustifiably cancelled referrals. They constantly warned the NIJZ and the MZ about the discrepancy and repeatedly asked them to turn off the automatic control until the communication problems between the local and central systems are resolved with the software houses. The NIJZ and MZ stand by the position that the system works according to Article 15b of the Patients’ Rights Act. In a letter to the Ombudsman, UKC LJ apologised for the mistake to the complainant and all other patients who, due to inconsistent communication between the local and central systems, were inadvertently burdened with obtaining new referrals.

The Ombudsman deemed the complaint justified. He addressed his findings and a proposal to NIJZ and MZ. Although, according to the NIJZ and the MZ, this should be functioning, in practice there are problems experienced by patients, and as a result, health care providers also have extra work. The Ombudsman expects the competent authorities (MZ and NIJZ) to eliminate the problems in the shortest time possible and inform the Ombudsman of the result. The Ombudsman suggested to the MZ (or NIJZ) that it establish communication with healthcare providers in which there are problems with the deletion of referrals and, in cooperation with them, find solutions in the shortest time possible that will be suitable for both patients and health care providers.

The NIJZ responded to the Ombudsman's findings and highlighted its activities to ensure that the eNaročanje system and the work of contractors run as smoothly as possible. They see the main reason for the problems in the health care provider. The MZ also sees problems with the health care provider, specifically with external software houses that take care of the provider's information technology. However, the MZ asserted that such complications can be avoided by establishing a Central Health Information System and a central digitisation provider, which are regulated in the proposal of the Digitalization of Health Care Act, which has been in the legislative process since 14/06/2023. (EPA 872-IX). 9.4-13/2023