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The Challenges of e-Appointment: Process


Modeling, Infrastructure, and Organizational
Context

Article February 2004

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The Challenges of e-Appointment:
Process Modeling, Infrastructure, and Organizational Context

Ralf Klischewski
Hamburg University, Informatics Department
Vogt-Klln-Strasse 30, 22527 Hamburg, Germany
klischewski@informatik.uni-hamburg.de

Abstract reports on two cases of strategic efforts to introduce


This contribution focuses on the question why e- e-appointment applications in a given environment:
appointment has not (yet) become a killer (1) the Hamburg city state administration seeking to
application. It reports on two strategic efforts to improve its e-government services through allowing
introduce e-appointment applications in a given citizens to make appointments with administrative
environment: (1) the Hamburg city state admin- staff, and (2) the Hamburg medical association
istration seeking to improve its e-government seeking e-appointment solutions for doctors
services through allowing citizens to make appoint- practices to relate with their patients. In both cases
ments with administrative staff, and (2) the Ham- the original research questions were: What are the
burg medical association seeking e-appointment technical and organizational requirements which
solutions for doctors practices to relate with their must be taken into account during the development
patients. In both cases it turned out that the main of a web-based application for e-appointment? And
challenges on the road to successful e-appointment what are possible IT solutions to enable a successful
are a detailed understanding of the appointment- application in the given environment?
making process, a technical infrastructure which
enables communication between distributed From the systems development point of view these
software components, and organizational circum- research questions are related to the area of Web
stances which support the e-appointment applica- engineering [4]. While a well-founded understanding
tion. The summary indicates lessons learned from of the users needs is a key success factor for the
the web engineering as well as from the development of Web-based systems, it is especially
information management point of view. difficult to obtain this knowledge due to the techni-
cally and organizationally dispersed application envi-
1. Introduction ronment (cf. [5], [6], [6]). From the organizational
E-appointment refers to an internet-mediated point of view these research questions are related to
agreement between two or more parties as social information management [8]. Entries in calendars
subjects (person or institution) to interact at a indicating (non-)availability of staff members are
certain time and place for a certain purpose (e.g. highly valuable and well-protected informational
business meeting, medical treatment). Making an resources. A careful technical and organizational
appointment means finding an appropriate match management is required to make these resources part
between the openings in the calendars of the of a cross-organizational application.
involved parties and changing the status of these
calendars (from open to occupied for the agreed The inquiry in case 1 was carried out between
period of time). Since (a) appointment making is October 2001 and February 2002. A group of master
often a time consuming activity (especially for students were enrolled who (under the authors
service providers) and (b) appointment seekers are supervision) conducted two guide-based workplace
often frustrated by not being able to get a hold of interviews in one of the local offices as well as two
the other party/parties, it seems obvious that the use interviews with infrastructure experts. Subsequently
of information technology and the internet will they developed future application scenarios and
save work effort and relieve some of the process models, implemented a web-based prototype
inconveniences related to appointment making. The and presented the elaborated concepts and
relevance is even increasing because appointment implementation results to potential users and other
making is envisioned as a typical task for software city officials [3]. The inquiry in case 2 was carried
agents analyzing calendars, quality and other out between August and December 2002. A master
available attributes of service providers (see for student and the author analyzed the tools and the
example Tim Berners-Lees vision of the Semantic medical associations infrastructure available for
Web [1]) to provide their masters with reasonable doctors at that time, developed and sent out a paper-
answers to non-trivial information problems. based questionnaire to association members and
presented the evaluation of the answers (201 out of
This contribution focuses on the question why e- 2055 questionnaires had been returned in time) along
appointment is not (yet) a killer application. It with recommendations to the medical association and
a number of interested doctors [2].
In both cases it turned out that the main challenges service sector, mainly health care (hospitals, doctors
on the road to successful e-appointment are a practices), but also in the areas of photography,
detailed understanding of the appointment-making coiffeurs, wellness/sports, education, etc. Also public
process, a technical infrastructure which enables administrations consider implementing this function-
communication between distributed software com- ality as a part of their e-government services.
ponents, and organizational circumstances which
support the e-appointment application. Drawing on The most ambitious plans for building up a whole
the two cases mentioned above, the paper is infrastructure are found in the health care sector. For
organized as follows to explain these challenges in example, the UK government has signed a contract
detail: the second section outlines the scope of e- with an IT consultant company to provide an
appointment in practice and the available tools and electronic booking service for the National Health
services. The third section introduces phases, types Service (electronic booking is the process in which
and models suitable for conceptualizing appoint- patients' appointments for secondary care treatment
ment making and preparing for algorithmic han- are booked electronically by their GPs using
dling. The fourth section focuses on infrastructure computer systems). The service is supposed to
enablers and barriers. The fifth section discusses connect over 30,000 GPs with some 270 acute
organizational issues mainly from the point of view hospitals and community or mental health hospitals
of the owner of the e-appointment application. The and is expected to be in operation throughout
last section concludes with a summary and open England by the end of 2005 [9, 10].
questions.
3. Phases, types & models of appointment making
2. E-appointment in practice From scrutinizing scientific publications it seems that
E-appointment is closely related to electronic e-appointment is not on the research agendas. One
booking, electronic reservation and other types of reason for this might be that, at first sight, the
internet-mediated agreements on relations between implementation of an e-appointment application
time periods and resources in focus. Even though and/or service seems to be a rather simple task, i.e. to
there is no clear-cut distinction, one could say that organize a selection and/or match finding process
e-appointment emphasizes the agreement between between two or more well-structured data sets.
two or more partners as social subjects while However, our inquiries in organizations revealed that
reservation and booking rather refers to physical a conceptualization is necessary to interrelate the
resources (e.g. presentation room) or impersonal various technical and organizational aspects
and/or highly standardized services (e.g. flight, unfolding within an e-appointment process. To
secondary care treatment). The e-appointment identify requirements and to break down the problem
process is somewhat asymmetrical since in most into manageable fractions it proved useful to
cases we find one party (provider) offering distinguish different phases and types of appointment
appointments and the other one (seeker) looking for making. Regarding the phases, the core process of
appointments. Technically, the e-appointment appointment negotiation is distinguished from the
setting usually assumes that (1) the appointment activities before and after which may take place
seeker at the web front end and the provider at the according to the specific service and depending on
back end of the e-appointment application, and (2) what the appointment seeker already knows about the
the relevant calendar data of the provider is whole context. Table 1 provides a description of
technically integrated while on the seekers side a these phases along with typical examples of
human user (or a software agent) relates the e- appointment making from our case inquiries.
appointment application with the seekers calendar.
Note: all of these activities can be carried out without
On the market for e-appointment there are software any support through web-based systems. In practice
products and services. Software packages are to be we will always find several channels (web
installed on web servers providing the interface to application, email, phone, fax, mail, walk-in, etc.)
potential bookers as well as a database for which are used in parallel. Appointment seekers and
calendars and a mechanism for synchronizing the providers will even switch between those channels
data with remote calendar sources (e.g. and related media within one appointment process,
www.tracerra.com/calendar). Companies, which do but less likely within one phase of the process.
not want to run their own systems, may also use e-
appointment services (e.g. www.eschedule.de) that The focus of this contribution is on the core phase of
provide all the functionality for web users as well appointment negotiation. However, pre and post-
as an interface to the client organization. Server- appointment activities must be understood as they
based solutions for the companys intranet (such as might have a significant impact on how to support
MS Exchange Server in combination with MS the core phase. Within the negotiation phase itself we
Outlook) as well as electronic address books are have identified two basic types of appointment
not considered e-appointment applications. making: In case of the type consultation-hour the
appointment provider makes the first move by dis-
Not surprisingly, the application domains most playing the available appointment openings. In case
relevant for e-appointment are to be found in the
Table 1: phases within an appointment process (with examples from cases without any e-appointment support)

Phase Description Example (case 1) Example (case 2)

Pre- Obtaining detailed information A father needs to clarify a child Searching the Web a patient finds an
appointment about the service needed; identi- care issue: he calls the youth orthopedist nearby; to ask for a
activities fying the relevant/ responsible welfare office of his district to Tuesday afternoon appointment she
partner and/or service function find out who to contact and how sends an email to the address provided
finding out how to make to make an appointment
appointment

Appointment Offering/retrieval of available Not being able to come during Since the patient has no case history in
negotiation dates, negotiation and agreement regular consultation-hours, the this practice she is given the next
of appointment father calls the staff member in available appointment for standard
charge; on the phone they consultation (12 minute time slot)
agree on individual date & time

Post- Confirmation, cancellation or The child has become ill, the The email answering the appointment
appointment postponement of already agreed father calls in again to cancel request also instructs what documents
activities appointments; exchange of the appointment and ask for a the patient should bring for the
additional information new one consultation

of the type one-on-one appointment the appoint- standing of the medical problem to be addressed
ment seeker is the first to formulate her or his during that appointment).
choice by submitting a query encapsulating the
personal restrictions of dates and times. This leads Note: To complete the appointment making
to different models of the appointment-making (transaction) all four steps need to be completed
process, respectively (see table 2). For both types it successfully. From the usability point of view it
is assumed that (1) the appointment seeker has must be possible for users to return to the previous
already found/selected the right person to contact step from any intermediate state of the process (or
and/or the appropriate kind of service, and (2) the to repeat the whole process). The confirmation of
appointment provider has a reservoir of time slots the appointment provider may be preliminary e.g. if
which match the kind of service to be provided. In the calendar data at the basis of the web application
many cases these prerequisites are not trivial at all, is not synchronized with the original source while
and it might need a specialized dialog within the the session with the web user is still ongoing (for
pre-appointment activities to determine this (e.g. if example final confirmation may be sent out by
someone seeks a doctoral appointment, the assign- email as one of the post-appointment activities).
ment of an appropriate time slot requires an under-

Table 2: basic types of appointment making with process description and prototype implementation (case 1)
Type of app.-
Process description Prototype implementation (case 1)
making

1. provider displays all available dates & times (e.g. For a given kind of service the user is provided
calendar overview) with weekly tables of available dates (all of
consultation-
hour 2. seeker selects from display and submits his/her same length) within the consultation-hours; the
choice
user selects by mouse click and submits his/her
3. provider confirms selection
choice after providing some personal data into a
4. seeker confirms agreement (optional)
web form; confirmation is given instantly

1. seeker submits query with his/her choice and/or The appointment seeker may submit a request
restrictions by selecting from week, day, and/or daytime
one-on-one
2. provider presents set of available dates matching from pull down menus; the response lists a set
appointment
the query of available dates matching the query; the
seeker selects (radio button) and receives
3. seeker selects date from list
confirmation
4. provider confirms appointment
These are only the basic process types. In practice, we had planned for the following infrastructure set
process models for appointment making might up (see figure 1): incoming requests from web
need to be much more complicated, if e.g. more browsers are handled by an e-appointment service
than just one party is involved on one or both sides, component outside the firewall. At the front end this
dependencies with other dates must be taken into component processes requests and generates
account (e.g. minimum interval between therapy responses in HTML to web users. The relevant
sessions), necessary safeguards to keep web users calendar data is retrieved through XML requests and
from misusing the web application (e.g. one responses to and from the backend (see figure 2 for
appointment seeker tries to book all available the architecture of our service component prototype).
dates), etc. Inside the firewall a MS BizTalk server was planned
to function as the central gateway which transforms
4. Infrastructure enablers and barriers the XML requests into MS Exchange server queries
Any e-appointment service is highly dependent on and handles responses vice versa. An eApp-agent
the access to the data which represents the supplementing the Exchange server is supposed to
availability of those who provide appointments. In perform the routing task to any of the staff calendars.
some cases with no electronic calendar Calendars for services not directly associated with a
infrastructure inside the provider organization, all person are possible through opening accounts for
relevant data may be stored as original at the site virtual users (e.g. for consultation-hour of the
of the e-application service provider. However, in youth welfare office; see below).
most cases, the organization does internally operate
electronic calendars to administrate appointments In case 2 the situation turned out to be far more
of staff. These calendar applications may be difficult. The basic assumption was that doctors
standard package software (e.g. MS Outlook) or should not be advised to set up their own e-
integrated in domain specific application software appointment service (because of economic and
(e.g. for software for doctors practices). So the security reasons). In principle, the Hamburg medical
critical task is to set up a gateway which enables association was willing to run an e-appointment
request/response on relevant calendar data during service component on one of their web servers and to
online sessions or frequent synchronization of function as a secure gateway to the doctors
internal calendars with relevant data on the web practices. But in contrast to the city administration
server. In the case of multiple service providers there is no network linking the practice systems
and/or functions within the organization (each with among each other or with medical association servers
their own calendar) it additionally needs a routing (not even a virtual private network: in 2002 still all
function to enable information retrieval from and data exchange was handled offline). Even worse, in
manipulation of individual calendars. the practices we find a huge variety of software
packages for practice administration (there are more
In case 1 we found rather favorable conditions for than two hundred on the German market); most of
solving these tasks. The Hamburg city these do have some calendar functions. But there is
administration runs an IT infrastructure based on a no standard for interfacing those systems, and in
corporate telecommunication network as well as a many cases the calendar data is not accessible at all
suite of Microsoft products (PC operating system, without further programming effort. In result, even
office package, server applications), which enables those doctors who are willing to participate in and
the more than 30,000 staff members to securely support an infrastructure for e-appointment face
share files within the network, to set up group severe technical difficulties and/or would have to
environments or to use MS Outlook for meeting endure organizational disadvantages (see below) to
arrangements. For the e-appointment application compensate for interoperability problems.

Firewall
IT infrastructure Internet
(or other networks)
of administration
(case 1) Browser citizen

admin staff MS Outlook

citizen
MS MS
e-appointment Browser
Exchange BizTalk XML
server server service
admin staff MS Outlook
eApp-agent SMS
citizen

... WAP

MS Outlook citizen

Fig. 1. Envisioned e-appointment infrastructure (case 1)


XML

#WERT!

availability ? / !
application interactions-
logic service
XML Browser

#WERT! ? ? ?

xml html

! ! !
XML availability "consultation-hour"
#WERT!
selection "one-on-one"
confirmation
selection / confirmation Browser

WAP SMS
XML

#WERT!

Fig. 2. Architecture of the e-appointment service component prototype (case 1)

From evaluating the two cases we learned that infrastructure is suitable for implementing e-appoint-
certain aspects of the IT infrastructure on the back- ment on a large scale. However, the discussion also
end side are either critical enablers or barriers for e- brought up the following major arguments pointing
appointment applications: the minimum require- to organizational barriers of e-appointment imple-
ments are (1) standardized access to calendar data, mentation as well as related cost:
(2) an overall policy and implementation of secure
data transfer, (3) a gateway (including routing In public administration internet will always be
function) relating the front end application with only one among several (non-electronic, decen-
backend data bases, (4) an organizational responsi- tralized) channels for appointment making but
bility to set up and operate the gateway and front integration of these channels requires a significant
end application. An already existing highly inte- effort in itself.
grated network is certainly an advantage for any Savings in work effort (e.g. citizens using internet
project; but technical integration alone is worthless instead of calling up staff members) are difficult
unless also the organizational environment is to measure and do not sum up to a number of
suitable for implementing e-appointment. establishment posts to cut down on per department
thus there is only cost but no potential saving for
5. Organizational issues: is there an economy of the citys budget.
scale? Savings in work effort appear to be significant
Setting up an e-appointment service requires only if pre and post-appointment activities are also
investments sometimes more, sometimes less, supported through web-based applications but
depending on the already existing infrastructure these activities may not (easily) be standardized
and organizational circumstances. In any case, the for all administrative services, the required
appointment provider organization (or the network applications are not ready and their development
of organizations) setting up the service must ask is likely to be expensive.
itself whether the service value will justify the Systematic electronic access to data about staff
necessary investment. In this section we focus on availability may be interpreted as a means for
those organizational issues which have a significant control of individual work load and work
impact on this calculation of balance or may even performance thus it will probably not be
be the trigger for sponsoring decisions or accepted by the staff council.
discontinuation of the effort. An e-appointment service for public administra-
tion is likely to experience misuse (e.g. multiple
In case 1 there seemed to be an organizational appointment making by individual seekers) and
readiness for introducing e-appointment to a large violation (e.g. hacking attacks) safeguarding
portion of the administration. Because almost all of these risks is costly, and failures spoil the public
the administrative departments had indicated an image.
interest in using such a kind of application, the Appointment seekers submit data to the web-
citys e-government action plan of 2001 listed e- based service for which privacy considerations
appointment as one of eight overall basic functions/ and regulations must be taken into account this
applications (such as authentification, payment, contradicts the citys policy that any PC storing
shop, etc.) to be implemented. A prototype was personal data may not be connected to the
developed based on the requirement analysis at the internet.
youth welfare office in one of the citys districts. In result, the e-appointment effort was discontinued,
Confronted with the prototype solution (incorporat- despite the positive attitudes in the beginning. All in
ing the two core process models, see above), all, the organizational considerations indicated so
potential staff users, IT experts and city officials all many yet unresolved problems that there seemed to
agreed that this is an acceptable basis for develop- be no economy of scale justifying a significant
ing a real-life application and that the citys IT investment at that time.
In case 2 the survey of fall 2002 revealed that the implementation), the inquiries in the two cases re-
organizational readiness for introducing e-appoint- vealed different aspects of organizational difficulties
ment in doctors practices was rather inconsistent in relation to introducing e-appointment in a given
(see [2] for complete listing of questions and environment. However, most of these aspects are
answers; in the following basis of stated percentage likely to impact the e-appointment implementation
is the total number of valid answers for each decisions in any given environment, respectively. At
question; see also section 1). For example, only the end, the benefits of e-appointment implementa-
42% of the doctors operate electronic calendars, tion must outweigh the cost of service development
only 25% of those with handwritten calendars plan and of resolving all the organizational problems
to use software in the near future, and only 37% associated to this endeavor. In both cases reported
had heard about e-appointment before receiving the here, the main actors (the city administration, the
questionnaire. Besides, almost 30% are not ready medical association) were basically willing to take
for electronic data exchange, often because of responsibility for introducing e-appointment, but the
security considerations. Expectations towards the objections they had been facing amounted too high
future of e-appointment were rather modest: 50% from their point of view. Similar objections could be
expect a slight improvement of service quality traced in any other organization or network, and it is
(great improvement: 18%, neutral: 14%, problems likely that for the time being in most cases the
of acceptance: 18%), and only 38% expect a small economy of scale is not in favor of e-appointment
or major relief of work while 14% foresee implementation.
additional work and 29% fear major complications.
Given the choice between the two basic types of 6. Conclusion
appointment making, 38% opted for the process In this research we studied two strategic efforts of
model consultation-hour (i.e. display of available implementing e-appointment in a given environment.
appointments) and 48% preferred the one-on-one It turned out that the main challenges on the road to
appointment (i.e. answering individual requests). successful e-appointment are a detailed under-
standing and modeling of the appointment-making
To find out about the feasibility of an e-appoint- process, a technical infrastructure which enables
ment application for all doctors practices of the communication between distributed software
region, a few questions had been asked about the components, and organizational circumstances and
variety of appointment types and their attributes requirements for IT support which do not spoil the
(not to be confused with the process types of economy of scale. The problems encountered in
appointment making; see section 3). Answers fell these two cases are likely to be faced by other efforts
in a range between one and one hundred different which seek to set up a centralized e-appointment
appointment types, while the large majority service for a large organization or organizational
administrates ten or less different types (high network. To conclude: what can we learn from these
scores per number of types: 10: 19%, 4: 13%, 5: inquiries for future research and practice aiming at
13%, 6: 12%; 3% only run one type of appoint- making e-appointment a beneficial service for all
ment). Asked for the minimum and maximum time actors involved?
span for existing appointment types the answers
fell in a range between 1 and 25 minutes for From the systems development point of view
minimum (most: 5 minutes) and 10 to 360 minutes distinguishing different phases and types of the e-
for maximum (most: 30 minutes). appointment process has helped to identify and
model the activities within an e-appointment process
All in all, the survey revealed that the variety of and to understand the users requirements in
making doctoral appointments turns out to be a sufficient detail. However, if the application environ-
great challenge for the development of an e- ment is technically and organizationally dispersed,
appointment service component. Aiming to fit the the development of a Web-based service component
needs of the doctors practices the following must take precautions in order to avoid project
requirements contradict or are costly to balance: On failure: On the infrastructure level it requires
one hand it needs high flexibility to support all the standardized access to calendar data, an overall
different kinds of appointment making; on the other policy and implementation of secure data transfer, a
hand it must be easy to use for patients and gateway (including routing function) relating the
administrative staff. Taking into account also the front end application with backend data bases, and an
given interoperability problems (see above, section organizational responsibility to set up and operate the
4) and the doctors rather cautious expectations gateway and front end application. On the
regarding improvements of service quality and application level the types of appointment-making
efficiency, the medical association decided not to processes and the types of appointments (purpose,
take any further action at the moment. length, etc.) to be supported must be limited to a
manageable number in order to prevent high
Due to the different methods (case 1: prototyping; development costs and to maintain usability.
case 2: survey) and research foci (case 1: organiza-
tional barriers of e-appointment implementation; From the organizational point of view e-appointment
case 2: organizational readiness for e-appointment is also not an easy prey. Automatic access to and
manipulation of calendar information (in conse- research area, Information Research (7:3), 2002;
quence of outside events) are related to a number of available at: http://InformationR.net/ir/7-3/paper133.html
critical issues within the service provider organiza-
[9] Secretary of State for Health. The NHS Plan. A
tion. Therefore it needs an overall information
plan for investment. A plan for reform, The
management strategy which sets the frame for
balancing potential benefits with necessary in- Stationery Office, London, 2000;
available at: http://www.nhs.uk/nationalplan/
vestments in systems development, organizational
change and risk management. [10] YICHI Yorkshire Institute of Clinical and
Health Informatics. The National Booking Pro-
This research has focused on process modeling, gramme. Electronic Systems Implementation Project:
infrastructure, and organizational context as the Early Successes and Challenges, NHS Modernisa-
main challenges on the road to successful e- tion Agency, Leicester, UK, 2002;
appointment. This does not underestimate the available at: http://www.modern.nhs.uk/bookedadmissions/4
importance of usability, privacy, security and other 980/8979/YICHIfirstevaluation.pdf
issues. However, from our analysis and project
experience we find the challenges highlighted to be
intertwined with problems unique to e-appointment
and which therefore deserve some further research
in this application area. If they are solved, e-
appointment may become a killer application
after all.

7. References
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thesis), 2003;
available at http://swt-www.informatik.uni-hamburg.de/
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[3] Dring, T., and Schick, A. Phasenbildung und


Typisierung von Terminvereinbarungen als Vor-
aussetzung fr die Entwicklung von eAppointment-
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available at http://swt-www.informatik.uni-hamburg.de/
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