How We Wait
Waiting is a significant part of a medical visit experience. When visiting a medical office in person, we generally spend more time waiting for an interaction than we do interacting. Online primary care visits are no exception: on average, a patient will wait for about twice the duration of a visit (i.e. a 12-minute wait leads to a 6-minute interaction). That’s a long duration in “online time.”
Several ongoing projects at our telehealth company required us to have a fresh look at an online patient’s waiting experience. Waiting is mostly regarded as an issue to be mitigated solely by wait time reduction strategies. However, we made the assumption that there are possibly more dimensions to waiting than just time. This is how we became interested in a patient’s emotional response to waiting. We organized discussions and a small focus group to discuss different kinds of waiting experiences, created a shared definition of what waiting for a doctor meant, and suggested features for future development.
Why Improve a Waiting Experience for a Telehealth Company?
Our telehealth company guaranteed its users that they would be in touch with a doctor within 15 minutes of their initial request--a promise they fulfilled most of the time. But often enough some users would find themselves stranded in a long wait caused by a wide variety of predictable factors.
Frustration regarding wait time had a significant effect on our net promoter score as it tended to be one of the leading reasons for negative feedback. The relatively few users who were affected were more likely to become detractors. Therefore, improving the waiting experience could eventually improve our net promoter scores.
What is Waiting About? Initial Reflections on “Waiting”
I felt that our team needed to share a common definition of the word “waiting,” so we discussed what waiting for an interaction with a “service provider” meant to us. Our discussions could be summarized in three points:
1 - What are we waiting for?
We are waiting for an interaction with a person.
2 - How long are we waiting for?
Waiting occurs over time: sometimes it occurs over a long period, long enough that we might forget the exact time of the event we’re waiting for; or we’re waiting for an event that is expected to be imminent. What feels like a long time appears relative to the context in which we’re waiting.
3 - Where are we waiting?
The context of waiting varies: when waiting for an in-person interaction we may be standing, sitting, have access to entertainment or not. We may have to change location if we’re expecting multiple interactions.
Waiting remotely for an interaction occurring online or over the phone adds more components to the experience. The location in which we are waiting may influence our emotional state. Finally, expectations regarding the communication medium we are using to wait also influence the perception of the waiting experience.
What is waiting? Our definition:
The previous points helped us building this definition: “Waiting is the awareness of time passing until something that is expected to happen occurs.”
Creating this definition helped us frame the discussion points we would use during our focus group.
Focus Group Scenarios
We decided on four different scenarios to use as bases for organized discussion with our participants. Each scenario was relevant to aspects of our telehealth product, and included elements of comparison between in-person and online waiting experiences. We decided to focus on the following four scenarios:
In-office medical visit
DMV office visit - license renewal or similar
Bill inquiry or similar with a large company
Participants would be invited to describe their experience of waiting in each of these scenarios. Since we only had a small group of five participants we were able to have a very fluid conversation.
Focus Group Findings
The organized discussion got us to broaden our perspective on how waiting is perceived. Here is a summary of the discussions:
The Infinite Loop - Queuing on the Phone
Waiting on the phone appears to be the least enjoyed waiting experience. This is because the caller needs to remain focused on the call the entire time to avoid missing the awaited interaction. Users often expect to be waiting for services they typically call. Calls occur anywhere where a phone call is appropriate, and the actual location depends on the objective of the call.
Participants tended to seek out distractions during a wait, but only one participant routinely used apps available on his phone to distract himself while the call was on speaker (on the same device). Participants wouldn’t use their mobile phone apps while on a call out of fear of missing the call. Instead they would put the call on speaker or keep listening with headphones while seeking out other activities on other devices, or would engage with manual tasks such as housekeeping while waiting.
It was mentioned that some callers would just listen to the background music or pre-recorded hold messages and quickly get frustrated if the call was long. About 5 minutes appeared to be participants’ patience threshold. The frustration level with waiting appeared to be related to the quality of the waiting experience (music, messages, glitches) and its duration. Advertising for additional services were negatively perceived.
If the wait was long and the reason for the call was of low priority, and if there were other ways to access an equivalent service, then the user might easily give up. It appeared that the reason for the call, the urgency of the call, and the availability of positive distractions were all factors that would change the perception.
Some services tell the caller their position in the queue before talking to an operator. This is well received, but without a clear expectation of waiting time the caller still needs to pay close attention.
Trusted Services Will Call Back
Some services offer the option to call back the user if the delay in reaching an operator is too long--our telehealth service is one of them. With this option, customers don’t need to focus on the wait. The alternative, an excessive wait--i.e. a waiting time going beyond the caller’s expectations--leads to great frustration and a convoluted recovery process if there are no saved records of the previous interaction. During discussions about using call back options, participants shared that in all cases a representative had eventually called them back. However, this did not allay their general concerns about using call back options--they didn’t necessarily trust the service to call back, and were unclear about when to expect the call.
Callback is a feature of our telehealth service. When the request is made the doctor calls back when ready--this typically happens within 10 minutes or less. Everyone in the group had experienced this feature and was satisfied with it because it allowed users to do something else in the meantime. However, our team was also aware of customer complaints about excessive hold times or no call back at all. (While such complaints were rare, they had a potentially significant impact on our net promoter score.) The source of these complaints was not so much that customers were made to wait, but rather that they felt stranded without any explanation, and without the ability to reconnect. This was caused by the lack of an efficient workflow to avoid or mitigate such an outcome.
A Place for Waiting
The least amount of anxiety related to waiting appeared to occur during in-person visits to the doctor’s office. Patients trust staff to notify them when the doctor is ready to see them, and can therefore focus on their own tasks. If the wait feels too long, the patient can inquire about it. The space and the parameters of the wait are well defined and the patient can disengage with the act of waiting and seek out distractions. Surprisingly, participants agreed that a doctor’s office visit--with a comfortable environment provided--was the most acceptable environment for waiting, despite having longer average waiting times than online services.
The physical environment plays an important role in the perception of time: standing in line at the DMV for a few minutes is negatively perceived. Noise, discomfort, constant unwanted distractions and constant calls for ticket numbers is anxiety-inducing because it requires those who wait to be constantly active. It’s also not possible to step out of this environment because there are no reliable resources for customers to be notified of an imminent interaction. Visitors bear the responsibility of engaging with a clerk, or must lose their spot and need to queue up again. In this case distractions like TV, music, or advertising messages are likely to distract those who wait from the act of waiting and can be perceived as interference more than entertainment.
During the discussions the topic of waiting in restaurants came up. Some fast food restaurants manage the wait occurring after an order by giving customers a device that buzzes to signal that their order is ready. With this device, customers don’t have to focus on the wait i.e. standby near the counter until their order number or their name is called. Instead, the customer can sit at their table and occupy themselves with something else, and when the device buzzes the customer returns to the counter to exchange it against their order.
Finally it was noted that clinics and restaurants, and most physical spaces where waiting occurs in a waiting room, have a staff person available to provide information that justifies the wait time or provide assistance in the event of an emerging issue. In contrast, few online services appear to provide a type of support that’s dedicated to waiting.
Summarizing the focus group’s touch points, we could define the following design directions:
- Let users do something else while they wait
- No one likes waiting, and everyone would rather do something else than waiting. And everyone attempts to do something else while waiting.
- Provide a trusted environment for users to “disengage”
- But in order to let users do something else while waiting, the service needs to provide an environment where the user can entirely divert their attention to another task.
- Users must trust the service’s ability to reach them again and have ways to check on the wait’s progression.
- Provide a clear, unique and direct signal to “re-engage”
- The service may provide an environment to wait passively--without paying attention to the act of waiting--until the service actively signals the user again that the awaited interaction is about to start. The user must be able to clearly identify that signal and distinguish it among all other signals.
Set expectations regarding the wait
Time is a relative notion while waiting; discomfort and mistaken/inaccurate expectations regarding wait time appear to be the leading cause of dissatisfaction. So it’s important to set the user’s expectation regarding the wait and the events that may occur during the wait.
Be transparent, inform patients about the wait, keep the door open
Finally, users need to have resources to inquire about the progression of the wait. Users who wait also need to be able to communicate with the service about an emerging concern or issue that might occur during the wait.
By the end of the reflection process we were able to define a list of features and concepts that we would use as directions for future developments. We would need to evaluate their feasibility with our engineering team and consequently their cost. The next step would be to evaluate with Product the cost-benefits of each feature, prioritize them, and eventually schedule them within the road map.
Wait prediction service
The key aspect of improving a waiting experience was to make the wait as predictable as possible. For this we needed to channel as much relevant data as possible through a service that would let us operate a series of filters which in turn would trigger appropriate actions. Wait prediction had to become dynamic and flexible so we could eventually develop workflows that would address any known and future situations.
Supporting interactions with multiple mediums
We also needed to plan for supporting all the communication mediums a user could be using: phone calls, video calls, in-app messaging and notifications, system notifications, and SMS. This required us to develop a constant awareness of the user’s presence and availability.
Then we also needed a high-level workflow able to decide on an appropriate response to a given situation. The response would consist of choosing the medium(s) to reach and the message to deliver.
For example: a call could lead to video interaction, but if the user had logged off and lost internet connection the system should be able to make contact via phone call or SMS, and deliver an appropriate message to resolve the issue and increase the odds for the planned interaction to happen.
A visit status feature would let the patient know the current state of the visit and provide time expectations and a justification for the wait. So a patient who is waiting offline and expects a call back can check on the visit status anytime through any medium at hand: via phone, SMS, web app, or mobile app.
Call Back Options
A user facing any length of wait can decide to be called back when their turn comes, via whichever medium is prefered but also whichever medium is available at the time of call back.
This would require the service to select the most relevant medium at the time of call back according to the medium’s availability. For example, a user who wishes to be called back for a video call but appears logged off should be called back on a phone or via SMS.
Users need to be notified when the expected incoming interaction is imminent so they can prepare for it. The notification format or medium use should be appropriate to the user’s medium choices and online presence. We want to avoid many types of notification being received at the same time. For instance, if the user is still logged in to the mobile app, a system notification is sent. If the patient’s phone is locked, an SMS is sent. If the patient has initially called and requested a phone visit, the notification is also a call.
The content of the notification should also respond to the user’s choice. For instance if the user chooses a video call but their device is inactive, the message sent by SMS should indicate the procedure to reach the video visit.
Finally if the user doesn’t respond to prompts, their place in the queue might be swapped for the next available user.
The user’s patience threshold is a concept that would define a point in time where the user’s experience starts to degrade because the wait time is felt as excessive. It’s a variable that should inform what actions to take to prevent the patient from starting to get frustrated.
The estimated wait time before an interaction should define whether a user needs to remain online (phone, app, or web) or offline and wait to be contacted back.
Based on the time a patient has spent waiting for an interaction, the system should trigger notifications informing the patient about their visit status and provide alternatives. A medium wait (more than the average wait time) should trigger a comforting message. A long wait could trigger an appointment offer. The objective is to prevent abandonment.
Manage appointments while waiting
Patients should be able to schedule a further appointment if the wait turns out to be too long or if an emerging situation prevents them from being present. The goal of this feature is to provide an option that helps users remain engaged with the service when there is better availability.
Background music, entertainment and and promotional content during short online wait
A user who remains online must be aware of what signal to expect before the expected interaction occurs. A message must be delivered at the start of the wait to demonstrate what the user should expect--a sound, or a visual cue if the patient is waiting online. Waiting on a mobile app will require the user to grant permission for notifications, which may be a system notification associated with a sound and a vibration pattern. There must be a clear distinction in tone between the signal and any message or entertainment delivered during the wait.
Merging the Online and the In-Person Waiting Experience
Telehealth applications are often an added feature of medical practices, clinics, and hospitals. Patients who use such mobile apps could make use of them during in-person visits to check in, wait in different spaces than a waiting room--for example, a space dedicated to entertainment--or to interact with staff who are located in a distant location in a hospital campus.