The electronic referral system, as a key component of the family physician program, plays a vital role in improving service quality, reducing costs, and enhancing equity in access to healthcare. Despite efforts to implement this system in the country, evidence indicates that its deployment faces various technical, organizational, and cultural challenges. This study was conducted to evaluate the system from the perspective of users as the primary stakeholders.

This cross-sectional descriptive study employed a mixed-methods approach in 2022 in selected healthcare centers of Golestan University of Medical Sciences. The study population included users associated with the referral system, selected randomly. Quantitative data were collected using a validated questionnaire covering functional, technical, organizational, behavioral, cultural, managerial, economic, educational, ethical, and political domains and analyzed with SPSS18. For the qualitative part, an open-ended question was designed, and responses were analyzed using MAXQDA20.

A total of 110 users participated in the study. The highest mean score was observed for the functional factor (3.38±0.99), while the lowest was for the cultural factor (2.93±0.76). Regarding importance, the technical factor received the highest score (3.45±0.93) and the political factor the lowest (2.53±1.02). Qualitative analysis identified 11 key factor groups, including technical issues—particularly inefficient appointment design—staff shortages, and lack of coordination across referral levels.