Background: The public sector of the health care system provides justice and access for all people who need more specialized services through the referral system. If the challenges of the referral system are not identified and addressed promptly, the system will not be efficient and effective. The purpose of this study was to rank the reasons for non-referral of outpatient level 1 to level 2 in the electronic referral system of Golestan province in 2019. Methods: In this descriptive and cross-sectional study, 431 outpatients participated from the pilot hospitals of the e-referral system in Golestan province, who did not refer to the level 2 specialist despite that an appointment was set by the system. The participants were selected using a stratified random sampling method. Data were collected using a questionnaire and analyzed by descriptive statistics and Friedman test in SPSS 23 software. Results: The most important reasons for patients who were not  referred from level 1 to level 2 in the electronic referral system included the presence of a trusted and familiar physician, inability to pay the visit of a specialist, and high cost of transportation from home to the designated specialist, respectively. The gender of the specialist physician and lack of guidance on referral to the specialist physician were indicated by the referral center. Patients ranked the reasons of not referring to the specialist differently (P < 0.001). Conclusions: The current status can be improved by increasing the public confidence in specialized physicians working in the electronic referral system and making the specialized services free for the poor patients. Furthermore, raising the patient's awareness about using Level 2 specialized services through the mass media can help patients to benefit from these services.

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he World Health Organization considers the implementation of a family physician-based patients referral system to be a key point and a key step in improving the quality of services, reducing costs, effectiveness, and establishing equity in health care systems. Problems arising from the proper use of this system, especially after the emphasis and regulations in the family physician program, are still a concern of organizations, policymakers, managers, and service providers, and the achievement of any program to predetermined goals requires performance evaluation. It is and the challenges of the program hinder the community from benefiting from the available services. Despite various studies that T Introduction: Referral chain and its efficiency in different levels of health care system leads to optimal use of manpower and equipment. The purpose of this study was to explain the management challenges in establishing an electronic referral system. Materials and Methods:A qualitative study was conducted in Golestan province (Iran) in 2009 with inductive content analysis approach. Participants in the study were family physicians and specialists, managers and experts in charge of electronic referral system in the