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
Patient-centeredness is one of the six quality aims proposed by the Institute of Medicine to improve health care quality in the United States [34]. Web-based medical scheduling as a medical self-service offers a more patient-centered means to make appointments [6]. Most Web-based appointment systems are interfaced with a calendar-like list. Patients can browse and select the most convenient appointment time from the available time slots [21]. In contrast, patients are only given very limited options of available time slots in traditional appointment systems. Besides time slots, some of the Web-based systems allow patients to filter physicians by physicians’ attributes such as education background, experience, gender, and reviews from other patients [8].
Another convenience from improved patient access is that patients can fill out registration forms [26], get prescreened and review practice policies online [23] before they show up and this can smooth workflow and reduce misunderstandings.
In the self-servicing Web-based appointments, patients’ own descriptions of the reason for visit are often more detailed and illuminating [13]. Sometimes, patients might be uncomfortable or unable to vocalize certain symptoms (eg, sexual health problems) to the scheduler over the phone or in person, and they may make an untrue statement [2,13]. They tend to be more candid when they schedule online by themselves [13,20].
Reduced Waiting Time
Waiting is an indicator of service quality and a source of dissatisfaction that affects health care outcomes and patient retention [45,46]. Long waiting time may make patients seek care from other providers and thus this can potentially cause a loss in revenue.
The most cited benefit of real-time scheduling is after-hour access [1,3,21]. Real-time scheduling requires minimal intervention of schedulers and thus can help reduce the waiting time caused by human factors. The available time slots are transparent to patients through the Web interface. Patients are free to claim available appointment slots anytime and anywhere [3,20,37].
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 [3]. Although there is a concern that the ability to book in advance for chronic conditions might be diminished by same-day appointments due to the limited number of appointment slots [47], same-day appointments could produce positive outcomes as long as the provider can find a balance in his or her capacity. For providers, it is possible to reuse the time slots released due to late cancellations. These allotted time slots will be otherwise wasted if traditional appointment methods are used because of the longer turnaround time [8].
Barriers to Adoption
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 [41]. Only about 15% of public hospitals and 18% of private hospitals in Italy allowed appointments to be made online in 2008-2009 [39]. According to a study conducted by Google and Compete (a research vendor) in 2012, only 21% of patients booked appointments via computer or mobile devices [48]. Only about 7% of primary care practices in Canada and 30% in the United States offered Web-based appointment services in 2012 [49]. As of 2014, 67% of general practitioner (GP) practices in Scotland have websites and only 10% of them support Web-based appointments [35].
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 [3,13,28,37]. A large investment would be required for the providers to move toward new centralized Web-based scheduling systems [28].
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 [13,28]. Physicians have their own preferences in appointment patterns, whereas the booking preferences for different patients can be rather distinct and can change over time [4]. The “Mabel factor” depicts a situation in which a scheduler knows how to balance the practice’s available resources and human factors such as physicians’ preferences and patients’ needs [3,13]. It is challenging for real-time Web-based scheduling systems to achieve the same level of flexibility. In reality, physicians have to give up their preferred scheduling patterns to accommodate the simplified real-time scheduling rules [3,13].
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 [13,20]. Because schedulers are no longer involved in the appointment process, the systems should be capable of triaging patients and stratifying their risks accurately. Some practices just display static warning messages on their Web presence to stop patients from using their appointment systems for urgent conditions [13]. Some real-time systems still rely on human reviewers to screen for possible emergencies [3]. Very few real-time appointment systems reported in the literature can automatically identify emergency conditions [2].
Finally, many providers have a fear of losing control of their appointment systems, as they think patients may abuse the systems [20,23,44]. For example, patients may book appointment slots and end up with no-shows or late cancellations. As a result, valuable clinical time would be wasted. However, this issue can be addressed by enforcing predefined appointment rules, such as rules for cancellation and a penalty for no-shows [37]. Providers can also block out appointment slots and limit visit types to accommodate their schedules [20]. Blocking patients with no-show history and collecting copay up front when making an appointment can discourage no-shows [37]. Automatically generated email- or message-based reminders can also help reduce no-shows [37]. Some practices refuse to expose physicians’ open time slots, because they believe that patients might think the physicians do not work hard enough when they see many openings [21].
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 [1,8,30,31].