web based appointment system thesis

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Published on 26.4.2017 in Vol 19 , No 4 (2017) : April

Web-Based Medical Appointment Systems: A Systematic Review

Authors of this article:

Original Paper

• Peng Zhao 1 , MSc   ; 
• Illhoi Yoo 1, 2 , PhD   ; 
• Jaie Lavoie 3 , PharmD, MS   ; 
• Beau James Lavoie 4 , PharmD, MS   ; 
• Eduardo Simoes 1, 2 , MSc, DLSHTM, MPH, MD  

1 Informatics Institute, University of Missouri, Columbia, MO, United States

2 Department of Health Management and Informatics, School of Medicine, University of Missouri, Columbia, MO, United States

3 Vizient, Center for Advanced Analytics & Informatics, Chicago, IL, United States

4 Trinity Health, Livonia, MI, United States

Corresponding Author:

Illhoi Yoo, PhD

Department of Health Management and Informatics

School of Medicine

University of Missouri

Clinical Support and Education Building (DC006.00)

Five Hospital Dr

Columbia, MO, 65212

United States

Phone: 1 5738827642

Fax:1 5738826158

Email: [email protected]

Background: 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.

Objective: 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.

Methods: In February 2017, MEDLINE was searched through PubMed to identify articles relating to the impacts of Web-based appointment scheduling.

Results: 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.

Conclusions: 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.

Introduction

Background of web-based appointment system.

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 [ 1 ]. However, because these traditional methods require the intervention of schedulers, the ability to get a timely appointment is not only limited by the availability of appointment slots, but also by the schedulers and phone lines [ 2 , 3 ]. Patients’ satisfaction with appointment booking is influenced by their ability to book at the right time with the right health service providers [ 4 ].

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 [ 2 , 5 - 7 ].

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 [ 8 ]. The appointment services are cloud-based and can be integrated into health care providers’ own management systems. The other type of appointment service is proprietary appointment systems, which are integrated into patient portals on providers’ websites [ 9 ]. A patient portal is a secured Web-based service that allows patients to access their health information and communicate with their health care providers at any time [ 10 ]. In the United States, the growth of patient portals has largely been spurred by meaningful use (MU) requirements [ 11 ] because of the federal incentive program for adoption of electronic health records. To meet the requirements of MU and receive its incentives, the portal should be actively used by both the practice and patients [ 12 ].

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 [ 3 , 13 ]. Although the asynchronous Web-based appointment systems also use the Internet as a medium, they basically replicate the process of telephone-based appointment scheduling [ 13 ]. Under the asynchronous mode, if an appointment is requested outside of a provider’s business hours, it will not be processed until schedulers return to work. Normally, Web-based appointment requests are put in the same queue as phone-call appointments, and are thus limited by the backlog of phone calls in the queue [ 14 ].

Aims of the Study

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 [ 15 ] and Gupta et al [ 16 ]. To the best of our knowledge, this study is the first systematic literature review of the impacts of implementing Web-based medical scheduling systems.

Data Source

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 [ 17 ].

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. Figure 1 shows the logical relationships among the search keywords and their restrictions in the search builder of PubMed.

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.

Inclusion and Exclusion Criteria

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.

Study Selection

The process of identifying eligible articles is shown in Figure 2 . The initial query returned 587 articles, which were then filtered by publication date and language. 145 articles were excluded because they were published before January 1, 1990. Also, 16 non-English articles were filtered out. The remaining 426 articles were reviewed based on titles and abstracts and 336 of them were excluded due to low relevancy. The remaining 90 articles were then reviewed in full text, and 54 of them were excluded as they do not mainly discuss Web-based medical appointment services or a specific automatic or Web-based tool helping patients to choose a provider or make a medical appointment. The remaining 36 highly relevant articles discussing 21 Web-based medical scheduling systems were used in this literature review.

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 [ 3 , 13 , 18 - 29 ] discuss Web-based scheduling as standalone systems or components of portals, and report measurable or perceived (unquantified) improvements in some metrics after the implementation. Eight studies [ 1 , 2 , 5 , 7 , 30 - 33 ] conducted structured or semistructured interviews to sample patients’ attitudes toward specific Web-based appointment systems, and one study [ 34 ] surveyed both patients and providers regarding the transformation to patient-centered access to care. Six articles [ 9 , 35 - 39 ] discuss the necessity and the potential of computerized or Web-based appointment services. Three studies [ 8 , 14 , 40 ] retrospectively analyzed Web-based appointment data and compared them with traditional appointments. Two studies [ 6 , 41 ] surveyed people’s interest in using the Internet to schedule appointments (not tied to any specific Web-based appointment systems). One study [ 42 ] used a randomized controlled trial to assess the impact of a Web-based health management system. Another study [ 43 ] reported a Web-based provider recommendation system and validated it with a field experiment. These articles also vary in interventions and the granularity of information provided. Many studies were implemented in only a single clinic and had interventions that spanned from basic websites to detailed patient portals. Details provided about the specific components of each system and functionality vary from study to study and many offer only a vague description. Many studies also used multiple interventions simultaneously, such as a Web-based scheduling system with automated reminders and patient decision tools and patient portals. As a result, these studies cannot be directly compared.

Multimedia Appendix 1 summarizes the characteristics of the 21 Web-based appointment systems discussed in the literature. Of these 21 Web-based scheduling systems, 1 is based in Australia, 1 in Canada, 1 in mainland China, 1 in Taiwan, 2 in the United Kingdom, and the remaining 15 in the United States.

Many articles specifically measured reductions in no-show rate and waiting time as metrics to evaluate Web-based scheduling services.

Siddiqui et al [ 8 ] reported a no-show rate of 6.9% for dermatology appointments made with ZocDoc, significantly lower than the no-show rates of appointments made by traditional appointment making means (17-31%). The UK national online electronic referral and booking service “Choose and Book” was reported to have a significantly better rate of attendance than traditional appointment methods (95% CI 4.3, 20.5%, P <.01) [ 40 ]. Walters et al [ 25 ] reported the Web-based communication tool “Patient Online” reduced no-shows by 42%. The Dartmouth-Hitchcock Medical Center in New Hampshire has reduced no-shows by 40% after implementing an asynchronous clinical messaging service that allows patients to request, review, reschedule, and cancel appointments [ 26 ]. The US Department of Defense’s health care program Tricare achieved a no-show rate of 2% from Web-based scheduling compared with 8% from phone-based scheduling [ 20 ]. The Murry Hill Medical Group based in New York had a similar pattern in the no-show rate: less than 1% of Web-based appointments were missed compared with about 8% of phone-based appointments [ 21 ].

Cao et al [ 31 ] reported the Web-based appointment system (WAS) reduced the total average waiting time to 7 min from 98 min in a Chinese hospital because patients don’t need to queue up for the appointments when they use WAS. In the United Kingdom, the Department of Health requires the maximum waiting time for sexual health service appointments to be 48 h. The introduction of eTriage increased the percentage of patients offered an appointment within 48 h from 48% to 100% [ 2 ].

Besides reductions in no-show rate and waiting time, many other improvements were also reported from the literature and they are summarized in Figure 3 . The horizontal axis indicates the number of mentions of Web-based scheduling systems for each impact after implementing the 21 Web-based scheduling systems. To limit the number of categories (on the vertical axis), some of the close metrics were merged into a broader category. For example, “optimizing the referral process” and “streamlining operations” were merged into “improving efficiency,” as they both indicate improvements in the internal operations of the practices. Figure 3 shows that the most cited (10/21) positive change is “reducing staff labor,” closely followed by “improving satisfaction” (7/21), “improving efficiency” (6/21), “reducing no-show” (6/21), “reducing wait time” (6/21), “increasing revenue” (4/21), “increasing popularity” (4/21), “reducing cost” (3/21), “balancing patient load” (1/21), and “reducing wrong appointment type” (1/21).

Principal Findings

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 No-Show Rates

No-show is a significant cause of wasted clinical resources [ 40 ]. The patient-centered design in Web-based appointments has the potential to decrease no-show rates [ 8 , 25 ]. The reasons for the reduction of no-shows after implementing Web-based scheduling have not been systematically studied in the literature, but it could be attributed to the improved access in Web-based scheduling that allows patients to easily verify, cancel, and reschedule their appointments [ 25 ]. A possible reason is that patients feel more responsible for their appointments when they make appointments by themselves [ 44 ].

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 ].

Limitations

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 [ 24 ], whereas some practices have switched software service vendors [ 28 ].

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.

Conclusions

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.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Summary of the 21 Web-based scheduling systems.

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Abbreviations

Edited by G Eysenbach; submitted 07.10.16; peer-reviewed by D Miller, P Yu, X Zhang; comments to author 17.11.16; revised version received 31.12.16; accepted 04.03.17; published 26.04.17

©Peng Zhao, Illhoi Yoo, Jaie Lavoie, Beau James Lavoie, Eduardo Simoes. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 26.04.2017.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

A Web-Based “InstaSked” Appointment Scheduling System at Perpetual Help Medical Center Outpatient Department

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Patient’s satisfaction and comfort are the priorities of every hospital. With the traditional appointment system, patients have been experiencing long waiting time, which causes dissatisfaction. This study designed a new web-based appointment scheduling system the “InstaSked” which could reduce the waiting time experienced by patients. It is designed for patients (booking their appointment), medical secretaries (managing patient list), doctors, and management (monitoring patients). The system used an integration of the Six Sigma methodology, DMADV (define, measure, analyze, design, and verify), and BPM (business process management).

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Acknowledgments

The authors would like to thank all those who help in the completion of the project, especially UPHMC for allowing the study to be conducted in their vicinity. Special mention to the hospital staffs in supporting the study, providing all the necessary help the researcher needs.

Recommendations The researchers would like to recommend that a hospital management system should be applied. This would greatly help the doctors and secretaries in tracking their patients’ record. A database that includes patient’s records, results, consultations, and the like is highly recommended.

Creation of a mobile application version of InstaSked is also recommended, because it would be easier for the patients.

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Industrial Engineering Department, University of Perpetual Help System DALTA, Las Piñas City, Philippines

Sheily Mendoza, Ranzel Cloie Padpad, Amira Jane Vael & Cindy Alcazar

University of Perpetual Help System DALTA, Las Piñas City, Philippines

Graduate Studies, Mapua University, Manila, Philippines

Rolando Pula

School of Graduate Studies, Mapua University, Manila, Philippines

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Correspondence to Sheily Mendoza .

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Angelo Beltran Jr.

University of Perpetual Help System DALTA, Las Pinas, Philippines

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Cheongju University, Chungchongbukdo, Cheongju-si, Korea (Republic of)

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Bataan Peninsula State University, Balanga, Philippines

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Mendoza, S., Padpad, R.C., Vael, A.J., Alcazar, C., Pula, R. (2020). A Web-Based “InstaSked” Appointment Scheduling System at Perpetual Help Medical Center Outpatient Department. In: Beltran Jr., A., Lontoc, Z., Conde, B., Serfa Juan, R., Dizon, J. (eds) World Congress on Engineering and Technology; Innovation and its Sustainability 2018. WCETIS 2018. EAI/Springer Innovations in Communication and Computing. Springer, Cham. https://doi.org/10.1007/978-3-030-20904-9_1

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A web-based appointment system to reduce waiting for outpatients: A retrospective study

1 Department of Health Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an 710032, China

2 Department of Mathematics, Chang Zhi Medical College, Changzhi, Shanxi Province 046000, China

3 Division of Medical Service, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China

Fujun Shang

4 Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China

Danhong Liu

Caihong sun, yongyong xu.

Long waiting times for registration to see a doctor is problematic in China, especially in tertiary hospitals. To address this issue, a web-based appointment system was developed for the Xijing hospital. The aim of this study was to investigate the efficacy of the web-based appointment system in the registration service for outpatients.

Data from the web-based appointment system in Xijing hospital from January to December 2010 were collected using a stratified random sampling method, from which participants were randomly selected for a telephone interview asking for detailed information on using the system. Patients who registered through registration windows were randomly selected as a comparison group, and completed a questionnaire on-site.

A total of 5641 patients using the online booking service were available for data analysis. Of them, 500 were randomly selected, and 369 (73.8%) completed a telephone interview. Of the 500 patients using the usual queuing method who were randomly selected for inclusion in the study, responses were obtained from 463, a response rate of 92.6%. Between the two registration methods, there were significant differences in age, degree of satisfaction, and total waiting time ( P < 0.001). However, gender, urban residence, and valid waiting time showed no significant differences ( P > 0.05). Being ignorant of online registration, not trusting the internet, and a lack of ability to use a computer were three main reasons given for not using the web-based appointment system. The overall proportion of non-attendance was 14.4% for those using the web-based appointment system, and the non-attendance rate was significantly different among different hospital departments, day of the week, and time of the day ( P < 0.001).

Compared to the usual queuing method, the web-based appointment system could significantly increase patient's satisfaction with registration and reduce total waiting time effectively. However, further improvements are needed for broad use of the system.

Reducing outpatient waiting times has been the focus of a large number of studies [ 1 - 3 ] because waiting and treatment times are usually regarded as indicators of service quality [ 4 ]. The Patient's Charter of the UK Government sets a series of standards which state that all patients must be seen within thirty minutes of their appointment time [ 1 ]. Outpatient waiting time can be divided into two types: waiting before consultation, and waiting after consultation [ 5 ]. Time spent waiting before consultation has attracted much research attention, and can be further separated into waiting time for registration, and waiting time for consultation [ 6 ]. Because of China's limited medical resources, long waiting times for registration are common in the health care system, and the registration waiting time is generally much longer than the consultation waiting time. Long registration waiting times for outpatients have already become a long-festering healthcare problem in China [ 7 ]. For this reason, our study focuses on registration waiting time only.

In recent years, China has been in the process of implementing health care system reform [ 8 ]. The aim of the reform was to provide basic and convenient medical care. Easy access to a doctor is the first step for patients using health services. The traditional registration method (usual queuing method), had unacceptable waiting times, and placed great stress on clinic staff [ 7 ]. With the rapid development of the internet over the previous 2-3 years, some hospitals trialed the use of web-based appointment systems (WAS) for outpatients [ 9 ]. In 2009, supported by the Ministry of Health, all public tertiary hospitals began to use WAS. However, to date there are few studies about the efficacy of WAS in China. Thus, our study aims to evaluate the efficacy of WAS for outpatients, by comparing waiting times for the WAS and usual queue method, and investigating reasons for not using the WAS.

Study Participants

This work was approved by the ethics committee of Xijing hospital, Fourth Military Medical University. Informed consent was obtained from participants prior to the administration of study measures.

Study participants were recruited from outpatients of Xijing hospital, which is a tertiary hospital in Shaanxi province of China. A two-stage sampling method was adopted. First, from January to December 2010, 10% of all patients registering through the WAS were randomly selected for potential inclusion in the study, giving a total of 5641 patients. For each patient, detailed information including demographic characteristics, appointment, and contact data were obtained from the hospital statistics office. Then, from the selected patients, 500 were randomly selected for a telephone interview. The interview assessed satisfaction with the WAS and the time spent making appointments, and were performed by trained interviewers.

The comparison group completed a questionnaire and comprised 500 randomly selected patients who used the usual queuing method for registration. Interviewers distributed questionnaires to people queuing at registration windows, and supervisors were responsible for the collection of completed questionnaires after registration. The following questions were listed in the questionnaires:

1. What time did you join the queue?

2. What is your reason for not using the web-based registration system?

3. Are you satisfied with the usual queuing method?

4. What time did you register successfully?

The last question was confirmed by the registering nurses.

Main outcome measures

We evaluated the performance of two different approaches: the WAS, and the usual queuing method (Figure ​ (Figure1). 1 ). Using the WAS, patients are given an appointment number. At the designated appointment time, patients arrive at the hospital and get the registration that is allotted to their appointment number. These patients need not queue at the registration window. The patients using the traditional queuing method waste much unnecessary waiting time standing in line at the registration window to ensure a successful registration with a certain physician. The main outcome variables were: invalid, valid, and total waiting time based on the usual queuing method, and appointment-making time based on the WAS. "Invalid waiting time" was defined as the duration of time spent queuing for registration; and "total waiting time" was the total time spent queuing and obtaining registration, and consists of valid and invalid waiting time. Appointment-making time based on the WAS was the duration of time the participant spent making an appointment through the WAS.

Flow chart of outpatient registration methods . "*": WAS refers to web-based appointment system.

Statistical Analysis

We used SPSS 17.0 for Windows (SPSS Inc, Chicago, Illinois) for all statistical analysis. Continuous variables are presented as means and standard deviations. Categorical variables are presented as frequencies and percentages. The t -test, analysis of variance (ANOVA), Mann-Whitney U test, and Kruskal-Wallis H test were used to compare continuous variables, and the Chi-square test was used to compare categorical variables between the two registration systems. A two-tailed P -value < 0.05 was considered statistically significant.

A total of 5641 people made an appointment using the WAS in the study period, from which 500 were randomly selected for a telephone interview. Responses were obtained from 369 (73.8%) participants. For the usual queuing method group, 463 participants completed a questionnaire while queuing for registration, corresponding to a response rate of 92.6% (463/500).

The demographic characteristics of participants

Participant gender and residence distributions did not differ between the two registration methods ( P > 0.05). However, the age distribution was significantly different between the two methods, with the average age of participants being younger in the WAS group (Table ​ (Table1 1 ).

Demographic factors, degree of satisfaction, and waiting time for participants using usual queuing vs . web-based appointment system

Satisfaction and waiting time comparison between the two registration methods

Participants using the WAS reported a higher level of satisfaction with the registration method than those using the usual queuing method (71.7% vs . 49.0%, P < 0.001). In the usual queuing method, the average invalid waiting time was 86 minutes with a maximum of 13.5 hours; while the average valid waiting time was only 12 minutes (Figure ​ (Figure2). 2 ). Although the total waiting time of the usual queuing method was significantly longer than that of the WAS method (98 vs . 7 minutes, P < 0.001) (Table ​ (Table1), 1 ), there were no significant differences in valid waiting time between the usual queuing method and the WAS method (12 vs . 7 minutes, P = 0.321).

Box-plot of waiting time for usual queuing vs . WAS . "+": mean values; "WAS": web-based appointment system.

Reasons for not using the WAS

The most common reason given by participants for not using the WAS was that they were unaware of its existence (52.9%) (Table ​ (Table2). 2 ). Other factors leading to the non-use of the WAS were that people did not trust the internet (28.1%), and/or lacked the ability to operate a computer (10.4%). Only 8.6% of participants had other reasons, such as that it was casual decision to see a doctor, or that certain physicians had no extra "passports" to be booked.

Participant reasons for not using the WAS

Non-attendance following use of the WAS

The overall proportion of non-attendance following making an appointment using the WAS was 14.4%. Non-attendance rates differed among the 30 hospital departments (Kruskal-Wallis H test, χ 2 = 32.128, P < 0.001), and varied between 0.16% and15.7%. Neurosurgery, General surgery, Urology, Obstetrics and Gynecology, and Ophthalmology had the highest rates of non-attendance (Table ​ (Table3). 3 ). Non-attendance was higher on Mondays than on any other day ( P < 0.001). During daytime, the non-attendance rate between 1 pm and 4 pm was higher than the rate between 8 am and 11 am (24.6% vs . 10.7%, P < 0.001) (Table ​ (Table3 3 ).

Non-attendance rates in different subgroups of participants using the WAS ( n = 5 641)

One of the greatest complaints of the Chinese public is the amount of time it takes to queue for outpatient registration in China. From our investigation we noted that some participants even waited in line all night (13.5 hours) to ensure a registration with a certain physician. To effectively reduce registration waiting times in the usual queuing method is an urgent issue that needs to be resolved. This study demonstrates that that using a WAS could substantially increase patients' satisfaction with outpatient registration. Although some time is still needed to make appointments using the WAS, it can significantly reduce total waiting time, especially invalid waiting time.

Despite the benefits using of the WAS, many people still registered via the usual queuing method. One reason we identified for not using the WAS was that over half of the participants did not know that an appointment can be obtained through the internet. This indicates that more effort should be made by hospitals and health service providers to promote and encourage the use of the WAS. By using a WAS, hospitals and other health service providers can reduce their invalid waiting time and anxiety in queues. Another important finding was that registration demand varied according to day of the week and time of the day. After investigating patient's appointment time in the WAS, we found that 43.8% of patients (2471) wanted to see a doctor on Monday or Tuesday, and 71.0% of them preferred it to be in the morning. This makes it very difficult to obtain registration during these periods. By making patients aware of this, it would be possible to encourage them to register on days with a lower outpatient load. This will help distribute the registration demand evenly and improve the allocation of medical resources.

Non-attendance is one of the potential problems for hospitals using a WAS. In our study, the overall non-attendance rate was 14.4%. This is consistent with the non-attendance rates reported in related studies, which range from 12% to 27% [ 10 , 11 ]. We found that the proportion of non-attendance was higher on Mondays than on other days, which differs from another study, which reported that non-attendance rates were higher on Sundays than on other days [ 12 ]. The failure of patients to meet scheduled appointments disrupts the orderliness of medical care and wastes limited medical resources [ 12 , 13 ]. Some measures had already been adopted to address this issue, such as preventing patients who failed to attend appointments three times in the preceding 12 months from making any new appointments on the web.

Many studies have focused on reasons for non-attendance, and some reliable suggestions for improvement have been provided (e.g., using a reminder system) [ 14 - 16 ]. To improve the management of outpatients, we assessed non-attendance related factors in our study. We found that hospital department, day of the week, and time of the day were significantly associated with non-attendance. The proportion of non-attendance was higher following registration with medical specialists (e.g. specialists in Neurosurgery) and most non-attendance occurred in the afternoon.

Our study has some potential limitations. First, we failed to collect data on the reasons for non-attendance from the participants using the WAS, because the majority of people who failed to attend their appointments declined to give an explanation. Second, because our study participants were from a large tertiary hospital, and different hospitals may have a different WAS, our findings may not reflect WAS use in other hospitals. Some relatively small hospitals may not need to use a WAS, because they do not experience high demand for registration. Despite these potential limitations, our study demonstrated that the WAS is an efficient and satisfactory means of obtaining registration, and identified factors that contribute to not using the booking system. By identifying these factors, we intend to develop intervention strategies to further improve the usability of the WAS and provide convenience for patients.

Our study showed that use of a WAS can effectively increase patient satisfaction with getting a registration and reduce waiting times. A lack of information about online appointments was the main reason for not using the system. Non-attendance is an inevitable problem in the development of a web-based registration system. To increase the efficiency of the registration system, and to reduce non-attendance rates, further studies on various interventions such as the promotion of online registration, and use of a reminder system should be considered.

Conflicts of interests

The authors declare that they have no competing interests.

Authors' contributions

The initial idea was supplied by YW and YX. The protocol was drawn by YW and WC. Investigation was carried by DL, WC, HT, FS, ZT, CS and QY. Data extraction and analyses were performed by WC and YW. First draft was written by WC with contributions by YW. All authors commented and approved the final draft.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6963/11/318/prepub

Acknowledgements

Dr. YW was supported by the research program of Fourth Military Medical University. Prof. YX was supported by the National Science and Technology Support Project Grant (No. 2008BAI52B01) from the Ministry of Science and Technology and National Natural Science Foundation (No. 81072393) of China.

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• Open access
• Published: 14 November 2022

The use of various appointment systems among patients visiting academic outpatient centers in Kerman and the evaluation of patients’ perspective and satisfaction

• Fatemeh Bagheri 1 ,
• Farzaneh Behnam 1 ,
• Zahra Galavi 1 &
• Leila Ahmadian 1  

BMC Health Services Research volume  22 , Article number:  1344 ( 2022 ) Cite this article

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To optimize appointment systems, it is necessary to assess their users’ perspectives. This study aims to determine the use of various appointment systems among patients in academic outpatient centers and to investigate their perspectives and satisfaction.

This survey study was conducted on 332 patients or those accompanying patients in academic outpatient centers. A five-part questionnaire consisting of (1) demographic information, (2) willingness to use systems, (3) problems when using these systems, (4) problems after reserving the appointment, (5) recommendations and critics was used. The relationship between the system of interest and the available tools was examined by the Chi-square test, and the relationship between demographic characteristics and satisfaction was assessed using multiple regression.

The participants’ overall satisfaction towards appointment systems, regardless of the type of system, was 49.12 ± 16.04 (out of 100). Satisfaction with the appointment system using Unstructured Supplementary Service Data (USSD) was significantly higher than the other two systems (p = 0.03). Web-based application and Interactive Voice Response (IVR) were the most frequently used systems with 61% and 48%, respectively. More than half of those who had access to a telephone (56%) preferred the IVR appointment system, and most of those who had Internet access (71%) preferred the web-based application (p < 0.05). Among 137 participants who had access to both the Internet and telephone, 49% (n = 67) stated that they would rather arrange their appointment through the web-based application.

The web-based application and IVR are the most frequently used and favorable appointment system among the patients or those accompanying patients. Despite the availability of the infrastructure, the participant had moderate satisfaction with these systems due to their failures. Therefore, to have more efficient systems and increase patients or those accompanying patients satisfaction with these systems, healthcare authorities should have a plan to solve the problems of these systemes and use the capacity of information resources to inform the community regarding these systems.

Peer Review reports

To receive health services, patients have the most interaction with outpatient services. Patients’ satisfaction with outpatient services is influenced by factors such as quality of health services, ease of appointment, and access to required services [ 1 , 2 , 3 , 4 ]. Therefore, one of the issues for providing services to patients in outpatient care is planning and scheduling services for patients with the least waste of time [ 5 ]. In the past, the process of scheduling outpatient centers has been done by walk-in patients [ 1 ]. One of the biggest challenges of this traditional manner is the long waiting time in the queue to receive services [ 5 ]. A study shows that a non-user friendly appointment system is the main barrier to patients’ medical follow-up compliance [ 6 ].

With the advent of information technology and its growing use, especially in the field of health, many outpatient centers use appointment systems. These systems are designed to provide better services and speed up the workflow. An efficient appointment system can reduce waiting time, increase patient satisfaction, and save resources [ 2 , 7 , 8 , 9 , 10 , 11 ]. Today, various systems are available for patients or those accompanying patients to schedule their appointments in health care centers. Interactive Voice Response (IVR) is one of these systems that provide information to users through voice messages and receive appropriate responses from users, allowing their subscribers to schedule their appointment [ 12 ]. The Internet-based appointment systems allow the individuals to have a contactless booking through a communication network [ 7 ]. The two major types of internet-based appointment services include scheduling software as a service and proprietary Web-based scheduling systems [ 1 ]. Unstructured Supplementary Service Data (USSD) is another approach, which like IVR, is accessible through the telephone. USSD provide a structured menu to users by entering a numerical code in the mobile phone and allowing their subscribers to schedule their appointment by entering appropriate answers [ 13 ].

Kerman is the largest province and the most populated city in the southeast, Iran [ 14 ]. Due to the advancement of medicine in this city, some healthcare centers in this city are referral centers for providing care in the region compared to other cities in this province and even neighboring provinces. On a daily basis, many patients are referred to the outpatient centers affiliated with Kerman University of Medical Sciences (KUMS). Therefore, the high volume of patients and arranging their appointments are major challenges in these centers as the face-to-face manner lead to long waiting time for walk-in patients. KUMS with the aim of facilitating the provision of healthcare services to patients or those accompanying patients and in order to regulate their appointment has launched three appointment systems; web-based application, USSD, and IVR. To better manage the work processes of the healthcare centers and upgrade the developed systems, it is necessary to assess the views of their users. Therefore, the purpose of this study was to determine the use of the appointment systems by patients visiting the outpatient centers and to examine the perspective and the satisfaction of the users of these systems. The results of this study can help health care authorities to have better appointment systems to meet the needs of the community and improve the work process.

Study design

This survey study is conducted in Kerman. Out of six outpatient centers affiliated to KUMS, two centers (providing specialized and sub-specialized services) were randomly selected as the sampling settings. The patients or those accompanying patients of these centers could schedule their appointment through either the appointment systems or walk-in.

The types of appointment systems available in these centers include Web-based application, IVR and USSD appointment system. A web-based application that allows individuals to conveniently and securely book their appointments and reservations online through any Web-connected device [ 15 ]. IVR, is an automated telephone system that combines pre-recorded messages or text-to-speech technology with a Dual Tone Multi Frequency (DTMF) interface to engage callers, allowing them to provide and access information without a live agent [ 16 ]. USSD, is a protocol used by Global System for Mobile (GSM) Communications cellular telephones to communicate with the service provider’s computers [ 17 ]. In USSD, users can access a structured menu by entering a numerical code in the mobile phone. They can navigate the options menu and book appointments using the mobile keyboard [ 13 ].

On average, these centers provide services to 35,000 patients per month. Patients attending their appointment were recruited. In case patient was unable to fill the questionnaire or did not make his appointment on his own, indivituals accompanying patients were recruited. The inclusion criteria were (1) ability to read and write, (2) patients or those accompany patients who used appointment systems and (3) Willingness to participate in the study. The sample size for this study was determined using Cochran’s formula of 380 people ( P = 0.5 ). One of the researchers went to the selected centers and randomly invited at least 30 patients or those accompanying patients to complete the questionnaire every time.

Data collection tools

To collect data, three researchers-made questionnaires were developed. Each of these questionnaires consists the questions regarding one of the three appointment systems of the web-based application, USSD, and IVR separately. Six experts (two information technology specialists, two medical informatics specialists, and two health information specialists) confirmed the face and content validity of the questionnaires. The reliability of the questionnaires was also confirmed by calculating the internal correlation with Cronbach’s alpha (r = 0.87). The questionnaires consisted of five sections. The questions of all three questionnaires had the same structure and content in four sections, and only the questions of the third section were different among the questionnaires. The third section consists of the questions regarding the problems with the appointment system. Since each system has its specific functionality and workflow, the questions in this section were adjusted based on the type of appointment system. The sections of the questionnaire were as follows: (1) Demographic information including age, gender, level of education, and place of residence (4 questions); (2) Questions to measure the use and willingness of the participants to use the appointment system (5 questions); (3) Questions about the problems when using the system (this section includes 17 questions for the web-based application, 13 questions for IVR and USSD each) (4) Questions about the problems that participants faced after booking their appointment (5 questions) (5) There were two open-ended questions in the last section for providing the recommendations and critics. In total, 33 questions were used to assess the Web-based application and 29 questions for each the IVR and USSD systems.

The answer options were different based on the type of question. Thus, the answers to the questions in the first to fifth sections for the web-based application were as follows: eight questions with a five-point Likert scale from not at all to too many, five questions with yes and no options, seventeen multiple-choice questions, and three open-ended questions. Also, the answers to the questions in the first to fifth sections for each of the IVR and USSD systems were as follows: eight questions with a five-point Likert scale from not at all to too many, four questions with yes and no options, fourteen multiple-choice questions, and three open-ended questions.

The paper-based questionnaires were filled out in the researcher’s presence during the waiting period before the visit. If an invited patient or those accompanying patient did not want to complete the questionnaire, this person was replaced with a new patient or that accompanying patient.

Data analysis

Data analysis was performed using SPSS 21 to analyze the data. The answers of the third and fourth sections of the questionnaire were scored between zero and 100 (not at all = 0, only once = 25, a few times = 50, many = 75, too many = 100). Two-choice questions were scored as follows: yes = 100 and no = 0. To estimate the overall satisfaction score of the participants, the average score of the questions in the third and fourth sections was used. To analyze the satisfaction scores, the level of satisfaction was considered in three categories: low (scores below 25), medium (scores between 25 and 75), and high (scores above 75). The Chi-square test was used to measure the relationship between the system of interest and available tools. The relationship between demographic characteristics and satisfaction was investigated by multiple regression. Moreover, to investigate the relationship between satisfaction and the type of appointment system the Analysis of Variance (ANOVA) test was used.

Out of 400 distributed questionnaires, 332 (83%) questionnaires were completed and used for analysis. Seventy-five% (n = 250) of the participants were in the age group of 20–40. About 45% (n = 150) of the participants had an associate’s degree or bachelor’s degree. Seventy-seven% (n = 256) of the participants live in Kerman (Table  1 ).

The web-based application and IVR with 61% (n = 202) and 48% (n = 159) were the more frequently used appointment systems and the more favorable systems as well (n = 141, 42%; n = 117, 35% respectively) (Table  2 ).

Thirty-six% (n = 120) of the participants announced that how they inform about the appointment systems. Among these participants, 62% (n = 75) stated that they get information from their friends and acquaintances. The least sources of the information were public media including radio and television (%2) (Fig.  1 ).

The ways the participants inform about the appointment systems

Forty-one percent (n = 137) of the participants had access to both the Internet and telephone tools (fixed and mobile) to arrange their appointments. Moreover, 34% (n = 113) of the participants had only access to the telephone and 21% (n = 70) had only access to the Internet. In general, 96% (n = 320) of participants had access to at least one Internet or telephone tools. There was a significant relationship between the system of interest and the tools available for arranging the appointment (p < 0.05, Pearson Chi-Square = 83.37). Among 113 participants who had access to the telephone, 56% (n = 63) chose IVR as favorable system among the others. Among 70 participants who had access to the Internet, 71% (n = 50) preferred web-based application compared to other systems. Moreover, among 137 participants who had access to both the Internet and telephone, 49% (n = 67) stated that they would rather arrange their appointment through the web-based application (Table  3 ).

The participants’ overall satisfaction towards appointment systems, regardless of the type of system, was 49.12 ± 16.04 (out of 100). There was no significant relationship between the demographic characteristics of the participants and the satisfaction score (p > 0.05). The results of the ANOVA test showed that there was a significant relationship between the satisfaction when using the appointment systems and the type of system (p < 0.05). This means that the level of satisfaction with the USSD system when used was significantly higher than the other two systems (p = 0.03) (Table  4 ).

Seventy-one% (n = 236) of the participants preferred to receive a confirmation message after arranging the appointment. But only 52% (n = 174) of the participants stated that they had received a confirmation message. Of the participants, 332 individuals stated their viewpoints regarding the content of the confirmation message. They stated that the required information that should be included in the message is the date of the appointment (79%), Name and specialty of the provider (77%), the exact appointment time (73%), the exact address of the outpatient center (73%), and patient identity information (22%).

Regarding the best time for arranging the appointment via appointment systems, 52% (n = 171) of the participants preferred to have the possibility of 24 h responsive system. Of the participants, 15% (n = 50) chose the time interval from 6 am to 12 am, 18% (n = 61) from 12 am to 6 pm, 12% (n = 41) 6 pm to 12 pm, and 3% (n = 9) chose the time interval 12 pm to 6 am.

Forty-two% (n = 138) of the participants answered the question related to the problems concerning the appointment process and its system. The mentioned problems regarding appointment system include 37% (n = 51) failure of the system to save the appointment, 11% (n = 15) busy telephone line, 10% (n = 14) lack of insurance coverage due to miss-information, 9% (n = 13) mismatch between the arranged time and the actual time, 5% (n = 7) lack of existence of few specialists names in the list, 3% (n = 4) disconnection during arranging the appointment, 2% (n = 3) incorrect registration of details. The mentioned problems based on process include14% (n = 19) absence of the doctor on time, 5% (n = 7) limited time for making the appointment, 4% (n = 5) not accepting the appointment by admission personnel.

Figure  2 shows the average time that participants spent arranging their appointment. Approximately 40% (n = 132) of participants stated that their appointment process was successfully completed within 5 to 10 min, regardless of the type of appointment system.

The average time for arranging the appointment

Principal findings

In this study, the overall satisfaction level of the participants with appointment systems, regardless of the type of system, was moderate. Among these systems, the participants had higher satisfaction with the USSD appointment system during the process of arranging the appointment. The web-based application and IVR systems were the most frequently used systems and were more favorable among the participants. More than half of the participants who had access to the telephone preferred the IVR appointment system, and most of those who had access to the Internet preferred the web-based application. Participants who had access to both of these tools preferred the web-based application. Most participants informed regarding the existence of these systems by friends and acquaintances.

Based on our findings, the satisfaction level of the participants with appointment systems is moderate. This result is in line with the findings of other studies, which have shown that the appointment system has a positive effect on patient’s satisfaction with receiving services, reducing no-shows, reducing staff workload, increasing waiting time [ 1 , 8 , 9 , 10 , 11 , 18 ] and getting the right time with the doctor and 24-hour access to the systems [ 19 , 20 , 21 ].

In this study, although participants preferred to use the web-based application, the satisfaction rate with the USSD system is higher. This result is in line with the results of the Barron, et al’s study [ 22 ], Users’ satisfaction with the USSD system was very high than the other appointment systems. The reasons for this higher satisfaction can be due to its accessibility (by simply dialing a number) and easy to use USSD, and it works on almost all cell phones [ 23 , 24 ]. This system is sustainable and cost-effective support system to provide rural health care [ 25 ].

The results of this study indicated that the web-based application and IVR system are the most frequently used systems and more favorable among the participants. This result is consistent with the results of studies done by Yu, Heidari, Leung, Habibi, and Knight [ 9 , 23 , 24 , 26 , 27 ], which have shown that web-based application and telephone are the most popular appointment systems, and patients had satisfaction with these systems as they have benefits such as reducing the use of resource and staff, reducing waiting time and improving satisfaction.

In this study, more than half of the participants who had access to the telephone preferred the IVR appointment system, and most of those who had access to the Internet preferred the web-based application. This result is in line with the results of the study by Yu, et al’s [ 9 ] which showed that access to required tools and the understanding and ability to use appointment systems by the individuals are the strong motivators in using these systems. In the present study, the participants preferred to use the web-based application. Busy telephone lines and the need for several attempts to make appointments were the main problems of using the telephone to make an appointment. On the other hand, the use of the Internet-based appointment systems can not only be used as a tool to receive and provide health services, but also studies have shown that it can be used as a source of knowledge [ 28 , 29 ]. Therefore, combining the Internet-based appointment systems with knowledge resources can increase the motivation of users to use these systems.

Based on our findings, most participants informed regarding the existence of these systems by friends and acquaintances. This result is in line with the finding of the study by Yu, et al’s [ 9 ] which showed that the suggestion of friends or family were the two main ways to inform about appointment systems. As being informed about the existence of appointment systems will increase the use of these systems and consequently will lead to satisfaction, it is necessary that after the implementation of these systems try to apply various methods to introduce them to the public.

Most of the participants in this study wanted to receive a confirmation message to ensure about the accuracy of the arranged appointment. However, due to financial constraints, sending text message after arranging the appointment is restricted to randomly selected patients as well all patients who arranged their appointment at specific time periods. Providing the appointment confirmation message and also the reminder message regarding the appointment time can lead to an increase in user satisfaction. This result is consistent with the findings of studies by Junod Perron and McClean [ 30 , 31 ] which have shown that Short Message Service (SMS) reminders significantly increased satisfaction. In the study done by Nakhaee, et al’s [ 32 ], it has been stated that by sending a reminder SMS, it is possible to avoid office crowd due to forgetting the date or time of the appointment and reduce no-shows. Koshy, et al’s [ 33 ] also stated in their study that text messaging led to timely attendance and reduced patient waiting time.

The date of the appointment, the name of the care provider and her specialty, the exact time of the appointment, and the exact address of the center were determined as the most important content of the confirmation message by the participant in this study. Sending confirmation messages may increase patients’ assurance and providing this information will not only inform the patient about the correct process of making an appointment but will also reduce confusion and disruption on the day of the appointment [ 17 , 19 , 20 , 34 ].

Based on our findings, appointment systems significantly reduce the time of arranging the appointment and saved the participants’ time. This result is consistent with the results of studies by Zhang, Cao, Knight, and Mohebbifar [ 21 , 25 , 27 , 35 ], which have shown that appointment systems can effectively reduce waiting time.

The most frequent problems expressed by individuals are the failure of the system to save the appointment, the absence of the provider on time, constant busy telephone lines, the lack of insurance coverage, and the mismatch between the arranged appointment and the actual appointment. This result is in line with the results of study by Nakhaee, et al’s [ 32 ], which conducted a study to investigate the problems of appointment systems of physicians’ offices in Kerman from the perspective of secretaries and physicians. Busy telephone lines and lack of timely attendance of physicians in the office were among the problems reported in this study.

In this study, we had three limitations. The first one was the non-cooperation of people referring to the centers. Some people were not able to participate in the research due to lack of time, low literacy, and unfamiliarity with some appointment systems. Second, this research was conducted in several selected centers in Kerman; our findings may not be generalizable to other centers. Third, although mobile applications are one of the types of appointment systems, it was not implemented in this setting. So we could not evaluate mobile applications.

Future studies can increase the strength of evidence and the generalizability of the study by designing a study with a higher level of evidence (e.g., interventional studies). In future studies, the cost and time spent on these systems can also be compared together, and people’s satisfaction can be examined in different dimensions.

Implications of the study

Surveying the use and satisfaction of users of appointment systems provides the possibility for health policymakers to review these systems to improve them and achieve maximum effectiveness. Also, by examining the causes of non-use and dissatisfaction with appointment systems and considering which systems are most used, these systems can be designed and implemented efficiently. While the web-based application and IVR are the most used and favorable systems among people, and they can significantly save patients time, but the level of satisfaction with such systems is not as expected. This may be due to the above mentioned problems. These problems can cause dissatisfaction among people. The results showed that despite the implementation of this system, participants were more informed regarding these systems through less formal sources. Therefore, while planning to solve problems to have more efficient systems; authorities should use the capacity of information resources such as medias and social networks to provide extensive information.

The web-based application and IVR are the most frequently used systems and are morable among the participants. Most of the participants who have access to the telephone prefer the IVR appointment system, and most of those who have access to the Internet prefer the web-based application. Patients or those accompanying patients who have access to both of these tools prefer the web-based application. But despite the availability of the necessary infrastructure for patients or those accompanying patients to use appointment system, the overall satisfaction level of the participants with appointment systems, regardless of the type of system, is moderate.

Therefore, evaluating appointment systems and solving their problems to have more efficient systems can be effective in increasing people’s satisfaction. Given that most participants were informed of the existence of these systems by friends and acquaintances, it is suggested that officials use the maximum capacity of information resources such as media, social network and health staff to provide extensive information.

Data Availability

The data generated and analyzed during this study are available from the corresponding author on reasonable request.

Abbreviations

Interactive Voice Response

Unstructured Supplementary Service Data

Kerman University of Medical Sciences

Analysis of Variance

Short Message Service

Standard Deviation

Dual Tone Multi Frequency

Global System for Mobile Communications

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Acknowledgements

The authors would like to thank the participants of the study. They would also be grateful regarding the coopreation of the outpatiant settings affiliated to Kerman University of Medical Sciences.

This work was supported by the Kerman University of Medical Sciences (Grant number: 98001057, 2020).

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L. A. and F.Ba. and F.Be. contributed to the conception and design of the study, acquisition, and interpretation of the data, and drafting of the paper. F.Ba. and Z.G. were primarily responsible for the statistical analysis of the data. All 4 authors read and approved the final version of the submitted manuscript.

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Correspondence to Leila Ahmadian .

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In this study, we did not collect identifiable personal data. The questionnaires were completely filled out without names, surnames, and other identifiable data. Therefore, to participate in the study, oral informed consent was obtained from the participants, and the participants were assured that their information would be kept confidential. This study was approved by the research ethics committee of KUMS (ethics code: IR.KMU.REC.1399.382). In this study, all methods were performed in accordance with the relevant guidelines and regulations.

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Bagheri, F., Behnam, F., Galavi, Z. et al. The use of various appointment systems among patients visiting academic outpatient centers in Kerman and the evaluation of patients’ perspective and satisfaction. BMC Health Serv Res 22 , 1344 (2022). https://doi.org/10.1186/s12913-022-08635-6

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DOI : https://doi.org/10.1186/s12913-022-08635-6

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