Getting online appointment booking right: The jurisdictional scheduling approach

Have you tried booking an appointment with your doctor recently? Was it as easy as making a reservation at your favorite restaurant? Why not? That’s what we were curious to know.

It turns out that current booking systems are fragmented. Appointments can be arranged by phone, email, portals, fax and Online Appointment Booking systems (OAB), often by multiple systems at a single location.

Communications can be lost since they can’t be tracked, patients fall through the cracks, delaying patient treatments and leading to poor outcomes. Ontario introduced OAB Standards in 2021 but it hasn’t led to widespread uptake. It took Quebec 10 years to get their system up and running, but that system is unlikely to work elsewhere.

All players, including patients, providers, organizations and government, agree on the need to break down digital silos and create better data infrastructure to bring about system transformation. This is necessary not only to provide a better, safer experience for patients and providers, but also for government and organizations to plan better, given their limited budgets.

We represent a team of researchers at the University of Toronto. After 30 years of studying digital health implementations, we came to the conclusion that the next steps towards interoperability should be directed at provider and service scheduling. Appointment bookings are the most frequent transaction in the entire healthcare system, exceeding lab tests and prescriptions by a large margin. They are also relatively simple compared to other data that we collect in the healthcare system.

The current approach for online appointment booking in Ontario is for each healthcare provider to implement a system in their own office. The systems do not talk to each other, nor do they talk to other systems.
This creates new silos that are difficult to break down. It forces everyone to start keeping a list of new websites for all the doctors they see. Maintaining databases with all the different online appointment booking systems across the province makes no sense. It increases administrative effort and slows clinics down. It’s the opposite of what was intended.

So what’s the solution?

In February 2024 our team published, Measuring and Managing Healthcare Supply and Demand in Real-Time. In it we presented a system design that aggregates all provider, location and organization schedulers within a jurisdiction into a single Jurisdictional Scheduler (JS).

Individual EMRs are linked to the JS through APIs. This includes, for example, physicians, allied health providers, labs, DI facilities, walk-in clinics, ERs, clinics, hospitals and programs.

Apps enable patients to book appointments with their doctor, their pharmacist and their specialists using a single solution. Data is available bi-directionally in real-time, just like GoogleMaps. All users contribute to and access system-wide scheduler data as well other user-identifying information, such as name of provider/location, contact info, specialty, language spoken and gender.

All users would have accounts that would be maintained by the users themselves. For providers and organizations, accounts would function as profiles that could be searched by other users.

Apps would be developed, providing users a digital front door to the JS with a consistent interface, two things sorely missing from the current piecemeal approaches. Providers could also access the JS directly from their EMRs with no need for another password.

The JS would have an adjudicator function that would apply booking rules. There would be basic rules that apply to all users such as those found in the Ontario OAB Standards.

Providers could customize their own rules such as a specialist only allowing booking if patients have a referral. A referral could be logged into the system as a digital token. Another rule might be that a family doctor would only allow booking by patients on their roster.

Patients needing a family physician could search based on geography, preference, gender, etc. A patient with an acute problem such as a laceration could search the system for walk-in clinics and ERs and join a transparent queue. They could show up just in time, saving hours sitting in a waiting room.

Apps, as mentioned above, could be developed by vendors for users to access the jurisdictional scheduler. Apps would be interchangeable because of standardization of data and processes. This would enable competition in the digital health system like never before, driven by individual consumer choice, not procurement.

Organizations and governments would have access to aggregated data to aid in planning. Ontario Health Teams (OHTs) could check the status of any component of their organizations – clinics, providers, admin, locations and programs in real-time. For example: appointment wait-times and physicians taking new patients. New providers and clinics could be added flexibly if they already had accounts in the JS.

Government could view components of the system at any point in time to measure supply, demand, access and wait-times. Data could be subdivided by region, primary care, specialties, ERs, hospitals, LTC and patients needing a primary care provider. This would enable planning without the months to years delay at present.

In April 2023, the Ontario MOH issued a ‘Digital health strategy refresh’. Among other things, it called for a digital front door, connecting all major digital and data users, building on Health811, seamless integrated care and simple digital tools for frontline providers that are not a burden. The jurisdictional scheduler concept solves all these problems elegantly in real-time.

The healthcare system is strained due to increased demand and poor efficiency. Patients are bearing the brunt; providers are burning out and quitting. Government is already paying for this – even if it can’t be measured.
We recommend the following steps.

The government should regulate:

• The building of a central repository of appointments and requests for appointments. This will enable a real-time view of supply of and demand for care. It will ensure the market can respond to market needs while ensuring standardization of appointments.
• The setting up of a user account system for patients, providers, facilities and organizations with API access. The accounts should be user managed and could be used for other systems, such as e-referrals, e-lab reqs, e-prescribing, as well as a patient portal system.

The government should incentivize:

• The building of apps by vendors that allow viewing and working with data by patients, providers, facilities and organizations. With standardized data, it would be easy to switch apps without migration, leading to innovation by competition not monopolies.

There’s a saying, “If you want to go fast, go alone. If you want to go far, go together.” We welcome your thoughts and ideas. Feel free to reach us at the contact info below.

Dr. Karim Keshavjee is the Program Director for the Health Informatics Program at the University of Toronto. Contact him at: karim.keshavjee@utoronto.ca. Dr. Jonathan Marcus is Adjunct Professor, IHPME, University of Toronto. Contact him at: jonathan.marcus@utoronto.ca.