Online reservations: Letting patients make their own appointments

Some practices rave about the money and time they've saved by allowing patients to schedule visits through the Internet. But so far, most physicians aren't that enthusiastic.

By Neil Versel, amednews correspondent — Posted March 22, 2004

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Within five months of Murray Hill Medical Group in New York giving its patients the option of booking appointments over the Internet, the 34-physician primary care practice was able to eliminate five of its 18 telephone scheduling positions.

Today, more than two years later, about 35% of patients schedule their own appointments online, saving the practice more than $170,000 per year in staff salaries and benefits, according to Murray Hill managing partner Jeffrey Friedman, MD. Revenue is up as well, as patients can make appointments overnight and on weekends, allowing the practice to fill leftover or early-morning slots. "On average, a doctor will fill three overnight slots a month," Dr. Friedman says.

No-shows average less than 1% of patients who self-schedule, compared with 9% among those who make appointments by phone, because the automated system sends three reminders by secure e-mail.

Similarly, efficiency is up and costs are down at Tiny Tots Medical Centre in the Montreal suburb of Dollard-des-Ormeaux, Quebec, which takes automation a step farther.

"There are no people involved in the billing process, no coder, no eligibility checker. We don't have a paper-based superbill," says Tiny Tots Medical Director Benjamin Burko, MD. A superbill template in the system anticipates the CPT code for each type of visit, and allows the physician to upcode or downcode.

"Ninety-five of 100 visits go down the way you thought they would go down," Dr. Burko says. Physicians handle the 5% of coding that requires editing, while office staff never touches the bills.

Judging by these examples, allowing patients to schedule their own visits online sounds like a winning idea. But few practices have gone as far as Murray Hill or Tiny Tots, opening the scheduling book up to patients.

"As a patient, I'd love to have that capability," says Jonathan Teich, MD, senior vice president and chief medical officer in Waltham, Mass., for Healthvision, an information technology affiliate of hospital purchasing cooperative VHA. However, Dr. Teich adds, "Physicians are understandably hesitant about it. "

Dr. Friedman admits that the concept is "way out there." Indeed, he had to start his own company, NexSched, to develop an Internet-based booking engine after discovering nearly four years ago that neither Murray Hill's practice management system, Millbrook, nor its electronic medical records software, Logician, offered the technology. Likewise, Dr. Burko founded his own clinical IT company, Timing Corp., which he runs from a Montreal office while still maintaining a 20-hour-a-week pediatric practice.

But Dr. Frideman says potential customers of Marcellus, N.Y.-based NexSched often are reluctant to buy for two reasons: Physicians do not want patients to view inside their schedules, and doctors might think some patients are not informed enough to make their own appointments.

Dr. Teich, who's also an emergency physician at Brigham and Women's Hospital in Boston, says Healthvision has had discussions with practices about online scheduling, but has not seen much demand. "To date, whenever we talk with clients, they always say that they're interested but not really sociologically ready to give patients that much control," he says.

The "Mabel" factor

For example, neither patients -- nor a computer program -- would know physicians' preferences in scheduling.

"Before you can successfully implement self-scheduling, you have to implement 'Mabel.' Mabel is the generic scheduling administrator who has been working for Dr. Smith for 35 years, and knows a thousand nuances and idiosyncrasies and preferences that have been silently established over the years," Dr. Teich says.

"She knows that Dr. Smith never schedules two short appointments immediately following one long appointment if it's Tuesday and there's a procedure visit coming up. Unfortunately for the computer world, it's extremely difficult to find out what Mabel really knows, let alone try and put it into an algorithm."

There's also a worry among some physicians that patients won't know how to schedule themselves, considering that practices often quiz patients about their conditions before deciding when they should come in, whether they need to come in, or if they need to go to an emergency department right away.

This is among the reasons that Northwestern Memorial Physicians Group has not put much time into researching online scheduling, says internist Lyle Berkowitz, MD, medical director of clinical informatics at the Chicago practice.

"We are not confident patients have the knowledge about how to schedule themselves correctly. We will wait and see how others do with this," Dr. Berkowitz says.

And, of course, there's a general worry about how to implement a system that could change the dynamic of the patient-physician relationship.

Although the 130-physician Sansum-Santa Barbara (Calif.) Medical Foundation Clinic has explored patient self-scheduling -- even looking at products from vendors, Epic Systems Corp., McKesson Corp., NextGen Healthcare Information Systems and IDX Corp. -- Chief Information Officer Tom Colbert says practice executives have chosen to tread lightly.

"Our physician leaders are very much in favor of it." However, Colbert says, "We haven't even broached the topic to our entire medical staff yet."

Colbert says Sansum has long-range plans for the practice to offer scheduling as part of a full suite of e-health services, including online bill paying and physician-patient clinical messaging. But that might not come until the multispecialty group upgrades its entire IT infrastructure.

"The small practices have a big advantage in that because they are more flexible," Colbert says.

Flexibility comes into play because successful scheduling is absolutely dependent upon tight integration between patient Web portals and in-office software, according to health care IT futurist Mark Anderson, chief executive of the AC Group consulting firm in Houston.

"The application must be interfaced with the practice management system. Without it, the practice must re-enter all of the information into their system, creating no operational savings," Anderson says.

Anderson estimates that at least 30 commercial vendors have EMR and management/billing products designed to handle online patient scheduling. "A lot of them offer it, but docs have been resistant to use it," he says. He disagrees with the idea that online booking is the domain of small practices; he says that large groups and hospitals have a great, unmet need for any technology that improves scheduling.

"Technically, it is very easy to accomplish this, and process-wise, the office could create workload criteria to allow this to happen."

Overcoming barriers

Those involved in selling physicians online scheduling systems say they're trying to overcome physicians' objections.

For example, Dr. Friedman says, a patient with chest pains should not be surfing the Internet. The NexSched system overcomes this, he says, by watching for such red flags and instructing those experiencing chest pains to call the office immediately or dial 911.

A few pioneers in the world of self-scheduling have had success with adapting to the needs of individual practitioners, but those do tend to be small operations.

For example, the NexSched package includes a tool called the Configurator, which allows each physician to decide what kinds of appointments patients may schedule online.

A new client, the 15-physician Student Health Center at Brigham Young University, Provo, Utah, makes use of this feature, Dr. Friedman says. For example, pediatricians at BYU do not want well-baby visits on Friday afternoons, so those times do not appear for patients younger than 3 years.

"It's specific down to the micro level," Dr. Friedman says, adding, "Humans can always override rules."

Gastroenterology Care Center in Miami opens its online scheduling to established patients seeking only in-office exams, not diagnostic testing or surgeries.

"We only do vanilla, follow-up, office visit-type appointments," says Alejandro (Alex) Fernandez Jr., executive administrator for the 11-physician practice.

"Not everybody uses it," Fernandez says. "It's not very user-friendly for new patients, because they need to be in our system first."

Additional rules help prevent abuse of the system. "If a person has three no-shows or more, you cannot make appointments on the Web," Fernandez says. The same goes for patients whose accounts have gone to collections.

Those practices with compelling reasons not to post physician schedules online might have other options for automating scheduling.

Arizona Center for Neurosurgery, a three-physician, office-based practice in Phoenix with a small staff, posts on its Web site the hours physicians normally see patients, but allows patients only to request appointments through the online portal; office staff must respond to confirm times.

"We don't mind opening up our books. It's just that there's a certain amount of knowledge that goes into scheduling for neurosurgeons," says office manager Abigail Bowman. "With a neurosurgeon, our schedule has to be different."

Healthvision is among the vendors that facilitate remote scheduling by physicians and other health care professionals, such as permitting a physician to schedule a CT scan at an affiliated imaging center, but Dr. Teich says there is not much demand yet for direct patient access. "With patients, certainly I've seen a lot of hesitancy," Dr. Teich says.

While Samsun-Santa Barbara mulls the merits and drawbacks of Internet-based patient booking, Colbert talks of an "intermediate step" under consideration: automated appointment reminders by e-mail or perhaps telephone scheduling via interactive voice response technology. "Older patients may prefer this," Colbert says of the latter idea.

Yet even something as commonplace as the telephone has its hazards. When GI Care Center put in place an automated voice reminder system four years ago, the no-show rate actually increased. Apparently, recorded voices, even in Spanish, did not sit comfortably with the considerable Hispanic population in the Miami area, Fernandez says.

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British system to allow patients to choose specialists

While physician practices and hospitals in the United States debate whether opening up their appointment books to patients might signal a loss of autonomy, the British National Health Service is moving ahead with a plan to let 50 million people in England in on its scheduling system.

Seen chiefly a means to alleviate a notoriously long waiting list in the government-run health system, the Electronic Booking Service also aims to give British patients something many Americans take for granted: the ability to choose medical specialists.

Patients today do not have any say in the appointment time or even the physician for nonurgent referrals. The laborious referral process requires the British primary care physician to contact a specialist, wait for a return phone call and then send a referral letter to the specialist. Only then does the specialist contact the patient with an appointment time.

This bureaucratic, authoritarian setup breeds patient apathy and frustration and largely is responsible for a no-show rate of more than 10%. "If you decrease it even 1%, the system pays for itself," says David Sides, a technology developer in London for Cerner Corp., Kansas City, Mo.

Cerner last fall won a 5½-year NHS contract to build the Electronic Booking System in England, though it lost bids for clinical components of a nationwide health IT infrastructure across all of Britain.

"The government's goal is to give patients choice," Sides says.

The booking system initially will help automate referrals from primary care to specialists. "The ultimate goal is for the patient to leave the office with an appointment," Sides says.

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External links

Murray Hill Medical Group scheduling system (link)

Sansum-Santa Barbara Medical Foundation Clinic (link)

Tiny Tots Medical Centre (link)

Gastroenterology Care Center (link)

Arizona Center for Neurosurgery (link)

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