It’s easier by far to make a reservation at a restaurant than for a medical test. I guess having a meal at a restaurant is far more important than getting an MRI, given that the restaurant people have made the process simple and convenient and effective for all concerned. Getting a medical test must be rare and unimportant, since no one has bothered to make it work well. Sure. I guess that lie is more comfortable than the other possibility, which is that medical system administrators and software providers are too incompetent, lazy or unmotivated to make things moderately convenient and up-to-date for their employees and customers.
Why this is an important issue
If you’ve gotten this far, you’re already an unusual reader. The vast majority of the leaders, innovators, experts and generally high-prestige people in healthcare would have tuned out and moved on as soon as they saw “medical scheduling.” Their guts tell them “medical scheduling isn’t important.” In terms of career growth and industry prestige, their guts are serving them well. However, in terms of making a real difference that will positively impact most people involved in medicine, their guts are misleading them.
Medicine has a real prestige problem. I’ve described the medical innovation spectrum, in which the exotic, future-oriented end, like AI and Blockchain, gets most of the money, conferences, attention and career-advancing opportunities. The more you move on the spectrum to simpler, proven, non-exotic things that can make a difference here and now for lots of people, the more you’re moving to the back office or basement, where poorly-paid, invisible people while away their time and whine to no meaningful audience. Here are details and examples.
Scheduling is one of those proven winners that remains largely unimplemented in major medical organizations. The fact that scattered medical groups have implemented it beautifully shows there are no technical barriers.
I can hear it now. Scheduling. Sure. What award am I going to win by implementing something restaurants do? I’m breaking new ground in personalized medicine while I’m curing cancer on the side! Away with your trivial scheduling talk!
I get it. There’s just a little problem. As I’ve detailed here and here and here and here and more, time and money loss and serious medical issues are caused by nuts-and-bolts problems in the medical system. If just some of them were improved, the funding for your precious futuristic projects could be increased! And, by the way, loads of patients would be better off on multiple dimensions, including not dying prematurely! You know, little things.
As an example of the impact, consider just this aspect of scheduling: automated follow-up (yes, it’s part of scheduling). Failure of follow-up problems:
“The impact on patient outcomes included missed cancer diagnoses.” Journal of General Internal Medicine.
“In fact, almost a quarter of all medical errors occurring in outpatient settings can be attributed to poor follow-up of abnormal test results and are believed to represent 25% of malpractice lawsuits involving failures or delays in diagnosis.” AACC
The Scheduling problem
There are an amazing number of dedicated, skilled, hard-working professionals in medicine. There are patients who have health issues who are often grateful for the service and care provided by those professionals. But both groups, providers and patients, are burdened by ancient, dysfunctional and incredibly expensive processes and computer systems that make things that should be quick and easy into something that is cumbersome and time-consuming, often yielding poor results. Everyone involved feels trapped and needlessly harassed. What’s going on here?
This is the horrible general scheduling problem in health care. To illustrate the issues in a concrete way, I’ll focus on scheduling a test as a follow-on to a procedure, and use my own experience as an example – an example that, sadly, is business-as-usual in this world.
A Cat Scheduling Example
Before getting into scheduling a medical test for me, let’s see what happened when I had to schedule a test for someone more important than I am – at least she seems to think she is – my cat, Priss. The comparison between getting tests for Priss and me will be instructive.
I have a cat, Priss. Priss is pretty chill; here she is thinking deep thoughts:
I take Priss to a local animal hospital, where she is well cared for. I get regular notes and emails telling me when something medical needs to be done for Priss. For example, here’s the header of an email I received last year:
Note that the email arrived near the end of August, 2018.
Here’s the top part of the mail:
Note that there’s a picture of a cat in the email – they know who they’re dealing with! They know Priss’s name, and they know she’s a cat, and not one of those friendly but face-licking, slobbering dogs who are incapable of using a civilized thing like a litter box.
Here’s the rest of the email:
They make it hard to miss the phone number or the online scheduling system they support to make an appointment, don’t they? They also spell out exactly what needs to be done. And darn, the email was sent EXACTLY one month, to the day, before the service was due. Please note: this is THEM taking the initiative to follow up, TELLING ME when something needs to be scheduled.
If this were a human hospital we were talking about, I would say “to make a long story short …” but because this is an efficient, modern animal hospital, I get to say “to tell it like it is …” all I had to do was click on the email, buzz through their easy-to-use on-line scheduling system, make an appointment that worked for them and for Priss, get a confirmation email back right away, and I was done. That’s it!
On top of it all, the people there are great, and care for Priss really well. There was a problem with her fecal test -- results back in a single day -- and the treatment was immediate and effective, no more than a day's delay for any step.
An MRI Scheduling Example
Now we turn to hospital scheduling for humans, specifically for me at the world-class hospital system, Mount Sinai. I’ve had some medical issues that have required MRI testing. See this for a description of the issue, with details about the testing experience and the conclusions that can reasonably be drawn from it.
I had 30 days of radiation therapy in early 2018. I was supposed to have MRI’s to see the results of the radiation six months and a year after the treatment. This is standard practice. I know from experience that the grandees at Mount Sinai Medical System haven’t gotten around to sending a team to the Hudson Animal Hospital to learn from their cat scheduling system, so they can put a multi-year project plan in place to implement something similar for their human patients. In a human medical world that worked as well as my local little animal hospital, I would have gotten a reminder a month before my MRI should have been taken.
Being the patient patient that I am, I waited until after the anniversary itself. Then I sent a friendly reminder to my doctor:
He replied the next morning with a perfectly reasonable response – given that he had to do the work that a vet wouldn’t have had to do.
His prompt reply was Feb 4. I heard nothing for weeks, so I finally reached out again three weeks later:
Again, the doctor in charge of the radiation center, doing clerical work well and promptly, work that he shouldn't have had to do, responded right away:
What happened next? More fun wasting everyone’s time. Remember, with a reasonable on-line system like restaurants and vets have, none of this would be needed!
A couple days later I got a voice mail, with a friendly person giving me the date and time for which my MRI has been scheduled – of course, without consulting me! I guess I must be sitting around suffering, anxiously waiting for the first possible moment at which I can get my MRI, at which point I’ll drop everything and arrive two hours early. Or not. Even better, this call isn’t from the MRI center, it’s from my doctor’s office, where someone has made an appointment for me, a couple days after the most recent request, weeks after the original one. So I return the call, explain I can’t make the appointed time, and is there any way I could talk with the MRI center and make an appointment myself? Well, she tries to be accommodating, and says it’s OK, but I also need to make a follow-up appointment with the doctor by calling her. I think I can manage this.
I call the number she gives me, which was the wrong number. I consult the web, and it takes a typically long time to find the center and its phone number for scheduling on the website. Mount Sinai management, it goes without saying, is totally on top of customer feedback and quality management. So they pop up an opinion survey. What happened with the survey is a lesson all by itself in the profound dysfunction of our medical systems in general, and Mount Sinai in particular. I will treat this event in a separate post.
I call what the website says is the right number, and keeping sarcasm – however warranted it may be – to a minimum here, after a journey through automated VRU’s and other wrong numbers, I eventually get to the person who can schedule me. Sure enough, she finds the order for the MRI in her system, and makes an appointment that actually works for me. Phew! I then, as instructed, call back the main doctor’s office and schedule a visit with him to go over the results, as I had been instructed to do. Please note this visit with the doctor I scheduled; it will start its own little trail of incompetence and waste.
After way too much effort on everyone’s part, I thought things were finally set. Silly me. I got this call a few days before my MRI appointment:
After a couple of attempts, I get through. I’m told that the room where the MRI machine is suddenly needs to have major work done, work that apparently couldn’t be scheduled in advance, making the machine itself unavailable. So pick another time. We work something out. I then call the doctor’s office and re-schedule my visit with him, so that it’s suitably after the new date of the test.
On the morning of the date of my original doctor visit, the one I called and re-scheduled, I get a voicemail saying in effect, “you’re coming into today as scheduled, right?” I admit that the nasty thought of ignoring the call crossed my mind, but my better self took control. I called and got through after a couple tries and explained the re-scheduling. The person verified that the new appointment had in fact been made, but that “someone else” must have failed to cancel the old one. Done. Except that it wasn't really "done." See the associated customer service post to see what happened!
A week later something came up and I had to move the appointment with the doctor. I called. After explaining what I wanted, the person said, didn’t you just miss a scheduled appointment with the doctor? Nope. Apparently the last person I talked with, whom I told about their mistake, failed to correct it. Again.
Do you use a calendaring/scheduling system, for example the one in Microsoft Outlook? Have you noticed that you can click on an event and change the date/time, so that it moves to the new time slot? Of course, you can delete the old one and make a new one from scratch if you really want to, but why would you? The evidence seems to point to the possibility that such a feature, which is standard on modern calendar systems, doesn’t exist in the paragon of modern software used by the leading medical system, Mount Sinai.
Conclusion
Follow-up of events, both one-time and multiple recurring, is a standard feature of modern scheduling systems. Self-scheduling by software is a widespread feature. It’s widely used, and benefits everyone involved. It’s not as though self-scheduling by software is particularly difficult for medicine. For example, the primary care office I use, OneMedical, has a convenient system that takes account of the length of visit you need, and gives you choices of providers and locations so you can pick what works best for you. Once scheduling is on-line, it is amenable to serious optimization techniques, which have been deployed with great success resulting in substantial savings and efficiencies in things like infusion centers and operating rooms. This is not possible with the primitive human-phone-based systems in widespread use.
It’s painfully obvious that the important people at medical centers prefer to spend time doing “important” things at the fancy future end of the innovation spectrum, rather than lowering themselves to implement practical, here-and-now improvements that benefit everyone. When will this change?
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