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Health care is changing with a new emphasis on patient-centeredness. Fundamental to this transformation is the increasing recognition of patients' role in health care delivery and design. Medical appointment scheduling, as the starting point of most non-urgent health care services, is undergoing major developments to support active involvement of patients. By using the Internet as a medium, patients are given more freedom in decision making about their preferences for the appointments and have improved access.
The purpose of this study was to identify the benefits and barriers to implement Web-based medical scheduling discussed in the literature as well as the unmet needs under the current health care environment.
In February 2017, MEDLINE was searched through PubMed to identify articles relating to the impacts of Web-based appointment scheduling.
A total of 36 articles discussing 21 Web-based appointment systems were selected for this review. Most of the practices have positive changes in some metrics after adopting Web-based scheduling, such as reduced no-show rate, decreased staff labor, decreased waiting time, and improved satisfaction, and so on. Cost, flexibility, safety, and integrity are major reasons discouraging providers from switching to Web-based scheduling. Patients’ reluctance to adopt Web-based appointment scheduling is mainly influenced by their past experiences using computers and the Internet as well as their communication preferences.
Overall, the literature suggests a growing trend for the adoption of Web-based appointment systems. The findings of this review suggest that there are benefits to a variety of patient outcomes from Web-based scheduling interventions with the need for further studies.
Traditionally, medical appointments have been made with schedulers over the telephone or in person. These methods are based on verbal communications with real people and allow for maximum flexibility in complicated situations [
The Internet has recently emerged as another means to make appointments. Web-based appointment scheduling has been a popular research topic. Several studies conducted satisfaction surveys and found that Web-based appointment scheduling is an extremely important feature, and most patients would use the service again [
There are two major types of Web-based medical appointment services, medical scheduling software as a service (SaaS) and proprietary Web-based scheduling systems. Medical scheduling SaaS has gained increasing prominence in recent years. These appointment systems are not built up by health care practices themselves, but are provided and maintained by health IT companies such as ZocDoc and InQuicker on a paid subscription basis [
There are two modes of Web-based appointment systems, asynchronous and real-time. In the asynchronous mode, appointments are requested through emails or electronic forms on providers’ website, and then manually processed by schedulers. In the real-time mode, patients can directly interact with providers’ scheduling management systems [
Despite the increasing adoption of Web-based appointment systems, their potential benefits are yet to be systematically studied. The purpose of this review was to examine the current body of literature about Web-based medical appointment systems, specifically in regard to their potential benefits to patients and providers. We also want to identify the most effective services or components of them and explore the benefits and barriers of implementation. It is not the intention of this work to review the literature regarding fundamental theories of medical scheduling or system design, which have been studied and reviewed by Cayirli et al [
In this study, we present a systematic literature review of Web-based medical appointment systems following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews [
A literature search was performed in MEDLINE using PubMed to identify pertinent articles relating to the impacts of Web-based appointment scheduling. The MeSH terms used in the search included “Internet,” “computers,” “cell phones,” “electronic mail,” and “appointments and schedules.” “Smartphone” used to be an entry term for “cell phones,” and it became a MeSH Descriptor in 2016. To include articles indexed by “smartphone” after 2016 and articles involving smartphones before 2016, “smartphone” was included in the search without any restrictions.
The literature search was initially performed in April 2016. Since then, in order to make this literature review up-to-date (by including new articles), we regularly conducted literature searches with the same search keywords. Our last literature search was carried out in late February 2017.
Logical relationships between the search keywords in the search builder of PubMed.
In this study, articles published only after January 1, 1990, were included, because articles published earlier than this time were unlikely to be relevant to Web-based appointments. We only included articles mainly discussing general Web-based medical appointment services or a specific automated or Web-based tool that assisted patients in choosing a provider or making a medical appointment. The exclusion criteria were systems that solely discussed email- or phone-based appointment reminders and systems not designed for use by patients. Articles not written in English were excluded too.
The process of identifying eligible articles is shown in
Trial flow diagram of identifying eligible articles.
Literature on this topic is very recent, with 16/36 articles published after 2010 and 35/36 published after 2000. The studies are highly heterogeneous in research design. More than one third (14/36) of the articles [
Many articles specifically measured reductions in no-show rate and waiting time as metrics to evaluate Web-based scheduling services.
Siddiqui et al [
Cao et al [
Besides reductions in no-show rate and waiting time, many other improvements were also reported from the literature and they are summarized in
Impacts after implementing the 21 Web-based scheduling systems.
The Web-based medical appointment reframes the way to communicate with providers’ appointment management systems. Compared with traditional appointment methods, Web-based appointment scheduling has unique advantages and disadvantages. In this section, the key benefits and barriers to the adoption of Web-based appointment scheduling will be discussed.
Patient-centeredness is one of the six quality aims proposed by the Institute of Medicine to improve health care quality in the United States [
Another convenience from improved patient access is that patients can fill out registration forms [
In the self-servicing Web-based appointments, patients’ own descriptions of the reason for visit are often more detailed and illuminating [
No-show is a significant cause of wasted clinical resources [
Waiting is an indicator of service quality and a source of dissatisfaction that affects health care outcomes and patient retention [
The most cited benefit of real-time scheduling is after-hour access [
The support of same-day or soon appointments by some real-time systems can help further shorten the time between when the appointment is requested and when the medical service is fulfilled [
It is well known that medicine has lagged in the adoption of new technologies. Although Web-based appointment scheduling comes with many benefits, some providers and patients are reluctant to use it. By 2007, only about 3.2% of the population in 7 European countries (Denmark, Germany, Greece, Latvia, Norway, Poland, and Portugal) had used the Internet to make medical appointments [
There are many reasons for the slow adoption. First, the transition requires the practices to give up legacy systems they have relied on and change the fundamental workflow and administration already established [
Second, real-time Web-based scheduling lacks flexibility in the medical setting because the automatic appointment systems are not intelligent enough to handle cases not predefined. Unlike the appointment scheduling in other industries such as airline ticket booking, which has strict rules, medical appointments are tailored based on the knowledge of physicians and patients, and thus can be rather flexible [
Third, safety is a concern. It is challenging to triage patients who made appointments through real-time Web-based appointment systems. Patients may misuse Web-based appointment systems for urgent conditions that need to be handled immediately by an emergency room or urgent care [
Finally, many providers have a fear of losing control of their appointment systems, as they think patients may abuse the systems [
In addition to the four main barriers, studies found that the following common problems from the patient side considerably affect the adoption of Web-based scheduling: unawareness of the Web-based appointment service, low penetration and distrust of the Internet, low computer skills, and the preference for verbal communications [
This review has a few limitations. First, the collection of literature has a long time span ranging from 1990 to 2016. With the rapid development of information technology, many systems, especially those implemented in 1990s and early 2000s, experienced significant changes after they were introduced and reported. Some of the original services have been discontinued and replaced with other services [
Second, many studies lack statistical research designs and have used multiple interventions at once. Although there are many improved metrics reported in the literature, it is difficult to determine whether these improvements are solely resulted from the implementation of the Web-based appointment systems. In addition, as many reported Web-based appointment services are components of health care Web services or patient portals, it is possible that the positive changes could be attributed to other components of the system.
Third, several studies have discrepant and even contradicting results. This is because the studies are from various sources with differences in care type, patient population, study period, and study design. Therefore, it is hard to compare their results systematically.
Fourth, many studies failed to report the information about assessment methods used in their studies, making it hard to judge their findings.
Finally, this work only reviews Web-based scheduling systems reported in the academic literature and does not reflect all systems available in the market.
In this study, we sought evidence from the literature to discuss the benefits and challenges of implementing Web-based medical appointment systems. Compared with traditional appointment methods, Web-based appointment scheduling is more patient-centered and has many advantages due to improved access. After implementing Web-based appointment systems, many practices have shown positive changes such as reduced no-show rate, decreased staff labor, decreased waiting time, and improved patient satisfaction.
Although these changes suggest Web-based appointment systems could produce positive outcomes, this assertion should be further reinforced by more sophisticated study designs. As in some studies, the Web-based appointment services are components of portals and it is hard to measure their impacts statistically. Some studies reported results without controlling for other factors. It is possible that the positive outcomes are produced by the other factors or by the combination of the Web-based appointment systems and the other factors.
Providers and patients both have reasons for the slow adoption of Web-based appointment scheduling. Cost, flexibility, safety, and integrity are major reasons discouraging providers from using Web-based scheduling. Patients’ reluctance to adopt Web-based appointment scheduling is mainly influenced by their past experiences using computers and the Internet, as well as their communication preferences.
Overall, the literature suggests a growing trend for the adoption of Web-based appointment systems. The findings of this review suggest that there are benefits to a variety of patient outcomes from Web-based scheduling interventions with the need for further studies.
Summary of the 21 Web-based scheduling systems.
general practitioner
meaningful use
preferred reporting items for systematic reviews and meta-analyses
software as a service
Web-based appointment system
None declared.