Stating the facts

It was now time to reflect on the research. This phase consisted of abstracting the research into “components”. Doing so helped us understand the dynamics at play and would later help with the ideation and the project prioritization.

Components of an appointment negotiation

Who will use the scheduling tool

Requesting an online appointment can involve several entities interacting together in various configurations:

Patients / Patient representatives, family members

Providers / May organize their own schedule / May look to negotiate appointments themselves

Staffer working for a practice or a clinic / May organize a provider’s schedule / Will look for availability / Will negotiate appointments on behalf of providers

Administrator / Will organize groups of providers / May organize provider’s schedule

Telehealth Platform's Customer Service / May interact directly with the patient when the patient calls to request a phone appointment / May manage appointments on behalf of providers or clinics

Types of scheduling

Talking to patients and providers we realized there were different types of scheduling interactions. We identified 5 kinds of scheduling methods. 

1. Instant availability: provider online now and taking visits
A patient is proposed a consultation with the first suitable provider available immediately (within a short period of time i.e. 5 to 20 mins).

2. Availability based on a live synced calendar
A patient chooses an appointment availability from a list of appointment slots generated from a dynamic calendar which accounts for all provider’s activities (online, in-person and personal calendars).

3. Planned online availability: the system offers available spots
A patient chooses an appointment from a list of available appointment slots. The practice has defined an online schedule for a provider and appointments are generated from the remaining availability on the schedule.

4. Reactive planning - appointments requested by asynchronous messages
A patient requests an appointment by message, the practice checks on the provider’s calendar and sends a number of appointment offers.

5. Reactive planning: appointment requested by phone or chat
A patient calls (by phone, video, or live chat) a practice during opening hours to find out about availability and negotiate an appointment time.

Multiple calendars define a provider’s schedule

Providers or staffer may maintain several schedules which may be associated or kept independent.

An appointment decision will be taken based on a consolidated view of all the schedules.

We anticipated a telehealth appointment to be duplicated (or exported) to an EMR schedule so the encounter is accounted for and included in the patient’s record. Syncing upstream towards a primary calendar would likely be challenging and would require deeper research.

We evaluated 3 kinds of calendars:

1. Primary calendar
For providers who work exclusively for a clinic or hospital and whose schedule is decided and managed by a third party.

2. Alternative calendar
For providers who work in several places and maintain several alternative schedules.

3. Personal calendar
Reflecting personal activities recorded on a personal schedule.

Patients make contact, then may request an appointment

The initial contact may have two components:

1. Questions about a consultation or reasons for a consultation
Patient describes what they are seeking or the reason for requesting a consultation or ask questions about the visit. These two components can be conditional to requesting a visit.

2. Appointment request
Most patients will directly ask for a visit they know they need—they often have a type of referral.

Appointment components

We listed a number of specifications that could define an appointment.

  1. Parties involved / Patient and associated parties (ex: family members) /  Provider and associated parties (ex: social worker)

  2. Time (of initial appointment) / Exact time / Time bracket (exact time to be specified)

  3. Validity period or expiration

  4. Reason for visits

  5. Comments or messages / Provider comments / Patient comments

  6. Recurring appointment

  7. Number of appointments planned / Period between appointments

  8. Communication modality for appointment / phone / chat /video

  9.  Attached documents

 

Appointment states:

  1. Pending

  2. Approved

  3. Active (Live/ Happening/ Occurring)

  4. Past/ Completed

  5. Missed

  6. Rescheduled/ Changed

  7. Cancelled

 

Appointment negotiation over the phone: finding a match

When interviewing patients we asked to describe a typical appointment request. We observed that multiple “rounds of negotiations” would occur until a match was found.

We have averaged the answers in the following description:

  1. Patient may state conditional requirements (availability, insurance, clinical approach)  >

  2. Provider answers >

  3. IF answer is positive, proceed to scheduling appointment >

  4. Providers defines type of appointment

  5. Provider declares first consultation slot and may add later availability 

  6. IF MATCH
    proceed to appointment details (patient details, location, preparation, etc…),
    IF NO MATCH
    Propose later availability in a general way (“we have more availability in 2 weeks”)
    May request that patient provides more information on availability

  7. Patient declares general availability

  8. Provider checks later dates and offers new appointment slots  

  9. IF MATCH / NO MATCH  (REPEAT STEP 5)

Choosing the appropriate appointment

Reflecting on the workflows followed by patients selecting a specialist consultation online it appeared to us that the consultation was preset by a staffer or a  provider beforehand. The appointment selection was systematically the product of negotiation vetted by a provider who in fact was giving referral.

So if a patient can choose from a number of appointments types it isn't guaranteed the appropriate appointment will be chosen. A scheduling mistake may create costly gaps in a provider schedule. Therefore providers must have simple ways to change the request or reschedule.

For the system to assign an appointment choice in answer to request and if there are more than one length of appointment available we must provide a clear expectation regarding the appointments objective. 

Rules must be established to show only the relevant appointments. A patient who sees a provider for the first time should be able to request a medication refill without prior medical evaluation.  

Referring to multiple calendars: usability challenge

Specialists generally use multiple scheduling systems. Our system is almost always secondary because most specialists don’t work exclusively on a telehealth platform —they are complementing their primary activity with us.

We role-played the tasks necessary to create an appointment for a patient who is declaring some general availability (ex: “I’m generally available on Tuesday afternoon after 4pm”) and found the process of setting an appointment was cumbersome:

Processing an appointment request while referring to a calendar that's external to the system where the request is made

1. Provider memorizes the request or takes notes on a notepad (paper likely)

2. Checks the online visit schedule on our application to check for conflicts

3. Then opens the primary calendar

4. Finds at least one match

5. Memorizes or takes notes

6. Compares to online visit schedule

7. Creates appointment proposals

8. When the appointment is confirmed, reports the appointment to the primary calendar

Providers must have the ability to—at least—import calendars to the online visit scheduler.

Challenges with imported calendars

We will need technical expertise on calendar formats and exchange of calendar data. At this point in the research we can only make assumptions about the way calendars work based on our own experience of standard format. We know from providers that some EMRs can export calendars, we don’t know yet if they can be edited or if calendars can be imported to EMRs.

We will have an issue if the activities performed on our online visit platform need to be accounted for on an EMR or whichever planning tool a practice or clinic uses.

We must reduce manual input. And if manual input occurs it needs to be facilitated.

Finally, a providers might not control their other schedules and providers may work with very little lead time to prevent conflict with the online visit schedule. We can expect conflicts to happen due to rapidly changing schedules and obligations stronger commitments with other organizations. Our scheduling system must have ways to highlight conflicts and address them.

Designing for flexibility

The system must be able to address most expected user behaviors and tolerate various level of engagements from providers. A behavioral therapist is generally very different from a speech therapist or a psychiatrist, they generally work in different environment and their attitude towards the telehealth medium varies.  

A patient looking for an appointment may have several options:

  1. The patient isn’t logged in and could call the telehealth service’s customer service to request an appointment with any provider in a given specialty.

  2. The patient could be logged in, choose a provider and send a message requesting an appointment.

  3. The patient is logged in and could choose a provider and call the practice to request an appointment and discuss an appointment.

  4. The patient is logged in and could choose a provider, then a consultation type and then choose an appointment time out of a selection made by the system

  5. The Patient has not described reason for visit

  6. The Patient has not given any indication of availability

Providers’ level of  engagement may range in such a way:

  1. Provider maintains an accurate online schedule

  2. Provider/practice maintained an online availability availability schedule but needs to compare it against other calendars before planning an appointment

  3. Provider has planned online visit schedule on external calendar that’s imported and taken as a reference to allocate appointments

  4. Provider/practice checks other calendars before manually creating an appointment entry

  5. Provider only enters new appoint on request and hasn’t imported other calendars

  6. Practice accepts phone calls to plan for online visits

  7. Practice accept to call back patients to discuss a visit

Being flexible with providers allows for building networks faster than the competition. We are still in a phase of adoption and specialty medical and wellness services is an emerging market for telehealth.