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

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

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,
process models for appointment making might
need to be much more complicated, if e.g. more
than just one party is involved on one or both sides,
dependencies with other dates must be taken into
account (e.g. minimum interval between therapy
sessions), necessary safeguards to keep web users
from misusing the web application (e.g. one
appointment seeker tries to book all available
dates), etc.
4. Infrastructure enablers and barriers
Any e-appointment service is highly dependent on
the access to the data which represents the
availability of those who provide appointments. In
some cases with no electronic calendar
infrastructure inside the provider organization, all
relevant data may be stored as original at the site
of the e-application service provider. However, in
most cases, the organization does internally operate
electronic calendars to administrate appointments
of staff. These calendar applications may be
standard package software (e.g. MS Outlook) or
integrated in domain specific application software
(e.g. for software for doctors practices). So the
critical task is to set up a gateway which enables
request/response on relevant calendar data during
online sessions or frequent synchronization of
internal calendars with relevant data on the web
server. In the case of multiple service providers
and/or functions within the organization (each with
their own calendar) it additionally needs a routing
function to enable information retrieval from and
manipulation of individual calendars.
In case 1 we found rather favorable conditions for
solving these tasks. The Hamburg city
administration runs an IT infrastructure based on a
corporate telecommunication network as well as a
suite of Microsoft products (PC operating system,
office package, server applications), which enables
the more than 30,000 staff members to securely
share files within the network, to set up group
environments or to use MS Outlook for meeting
arrangements. For the e-appointment application
IT infrastructure
of administration
(case 1)
admin staff MS Outlook
MS
Exchange
server
admin staff MS Outlook
eApp-agent
...
MS Outlook
Fig. 1. Envisioned e-appointment infrastructure (case 1)
we had planned for the following infrastructure set
up (see figure 1): incoming requests from web
browsers are handled by an e-appointment service
component outside the firewall. At the front end this
component processes requests and generates
responses in HTML to web users. The relevant
calendar data is retrieved through XML requests and
responses to and from the backend (see figure 2 for
the architecture of our service component prototype).
Inside the firewall a MS BizTalk server was planned
to function as the central gateway which transforms
the XML requests into MS Exchange server queries
and handles responses vice versa. An eApp-agent
supplementing the Exchange server is supposed to
perform the routing task to any of the staff calendars.
Calendars for services not directly associated with a
person are possible through opening accounts for
virtual users (e.g. for consultation-hour of the
youth welfare office; see below).
In case 2 the situation turned out to be far more
difficult. The basic assumption was that doctors
should not be advised to set up their own e-
appointment service (because of economic and
security reasons). In principle, the Hamburg medical
association was willing to run an e-appointment
service component on one of their web servers and to
function as a secure gateway to the doctors
practices. But in contrast to the city administration
there is no network linking the practice systems
among each other or with medical association servers
(not even a virtual private network: in 2002 still all
data exchange was handled offline). Even worse, in
the practices we find a huge variety of software
packages for practice administration (there are more
than two hundred on the German market); most of
these do have some calendar functions. But there is
no standard for interfacing those systems, and in
many cases the calendar data is not accessible at all
without further programming effort. In result, even
those doctors who are willing to participate in and
support an infrastructure for e-appointment face
severe technical difficulties and/or would have to
endure organizational disadvantages (see below) to
compensate for interoperability problems.
Firewall
Internet
(or other networks)
Browser citizen
citizen
MS
e-appointment Browser
BizTalk XML
server service
SMS
citizen
WAP
citizen
 XML
#WERT!
availability ? / !
XML
#WERT!
xml
XML
#WERT!
selection / confirmation
XML
#WERT!
Fig. 2. Architecture of the e-appointment service component prototype (case 1)
From evaluating the two cases we learned that
certain aspects of the IT infrastructure on the back-
end side are either critical enablers or barriers for e-
appointment applications: the minimum require-
ments are (1) standardized access to calendar data,
(2) an overall policy and implementation of secure
data transfer, (3) a gateway (including routing
function) relating the front end application with
backend data bases, (4) an organizational responsi-
bility to set up and operate the gateway and front
end application. An already existing highly inte-
grated network is certainly an advantage for any
project; but technical integration alone is worthless
unless also the organizational environment is
suitable for implementing e-appointment.
5. Organizational issues: is there an economy of
scale?
Setting up an e-appointment service requires
investments sometimes more, sometimes less,
depending on the already existing infrastructure
and organizational circumstances. In any case, the
appointment provider organization (or the network
of organizations) setting up the service must ask
itself whether the service value will justify the
necessary investment. In this section we focus on
those organizational issues which have a significant
impact on this calculation of balance or may even
be the trigger for sponsoring decisions or
discontinuation of the effort.
In case 1 there seemed to be an organizational
readiness for introducing e-appointment to a large
portion of the administration. Because almost all of
the administrative departments had indicated an
interest in using such a kind of application, the
citys e-government action plan of 2001 listed e-
appointment as one of eight overall basic functions/
applications (such as authentification, payment,
shop, etc.) to be implemented. A prototype was
developed based on the requirement analysis at the
youth welfare office in one of the citys districts.
Confronted with the prototype solution (incorporat-
ing the two core process models, see above),
potential staff users, IT experts and city officials all
agreed that this is an acceptable basis for develop-
ing a real-life application and that the citys IT
application interactions-
logic service
Browser
? ? ?
html
! ! !
availability "consultation-hour"
selection "one-on-one"
confirmation
Browser
WAP SMS
infrastructure is suitable for implementing e-appoint-
ment on a large scale. However, the discussion also
brought up the following major arguments pointing
to organizational barriers of e-appointment imple-
mentation as well as related cost:
In public administration internet will always be
only one among several (non-electronic, decen-
tralized) channels for appointment making but
integration of these channels requires a significant
effort in itself.
Savings in work effort (e.g. citizens using internet
instead of calling up staff members) are difficult
to measure and do not sum up to a number of
establishment posts to cut down on per department
thus there is only cost but no potential saving for
the citys budget.
Savings in work effort appear to be significant
only if pre and post-appointment activities are also
supported through web-based applications but
these activities may not (easily) be standardized
for all administrative services, the required
applications are not ready and their development
is likely to be expensive.
Systematic electronic access to data about staff
availability may be interpreted as a means for
control of individual work load and work
performance thus it will probably not be
accepted by the staff council.
An e-appointment service for public administra-
tion is likely to experience misuse (e.g. multiple
appointment making by individual seekers) and
violation (e.g. hacking attacks) safeguarding
these risks is costly, and failures spoil the public
image.
Appointment seekers submit data to the web-
based service for which privacy considerations
and regulations must be taken into account this
contradicts the citys policy that any PC storing
personal data may not be connected to the
internet.
In result, the e-appointment effort was discontinued,
despite the positive attitudes in the beginning. All in
all, the organizational considerations indicated so
many yet unresolved problems that there seemed to
be no economy of scale justifying a significant
investment at that time.
In case 2 the survey of fall 2002 revealed that the
organizational readiness for introducing e-appoint-
ment in doctors practices was rather inconsistent
(see [2] for complete listing of questions and
answers; in the following basis of stated percentage
is the total number of valid answers for each
question; see also section 1). For example, only
42% of the doctors operate electronic calendars,
only 25% of those with handwritten calendars plan
to use software in the near future, and only 37%
had heard about e-appointment before receiving the
questionnaire. Besides, almost 30% are not ready
for electronic data exchange, often because of
security considerations. Expectations towards the
future of e-appointment were rather modest: 50%
expect a slight improvement of service quality
(great improvement: 18%, neutral: 14%, problems
of acceptance: 18%), and only 38% expect a small
or major relief of work while 14% foresee
additional work and 29% fear major complications.
Given the choice between the two basic types of
appointment making, 38% opted for the process
model consultation-hour (i.e. display of available
appointments) and 48% preferred the one-on-one
appointment (i.e. answering individual requests).
To find out about the feasibility of an e-appoint-
ment application for all doctors practices of the
region, a few questions had been asked about the
variety of appointment types and their attributes
(not to be confused with the process types of
appointment making; see section 3). Answers fell
in a range between one and one hundred different
appointment types, while the large majority
administrates ten or less different types (high
scores per number of types: 10: 19%, 4: 13%, 5:
13%, 6: 12%; 3% only run one type of appoint-
ment). Asked for the minimum and maximum time
span for existing appointment types the answers
fell in a range between 1 and 25 minutes for
minimum (most: 5 minutes) and 10 to 360 minutes
for maximum (most: 30 minutes).
All in all, the survey revealed that the variety of
making doctoral appointments turns out to be a
great challenge for the development of an e-
appointment service component. Aiming to fit the
needs of the doctors practices the following
requirements contradict or are costly to balance: On
one hand it needs high flexibility to support all the
different kinds of appointment making; on the other
hand it must be easy to use for patients and
administrative staff. Taking into account also the
given interoperability problems (see above, section
4) and the doctors rather cautious expectations
regarding improvements of service quality and
efficiency, the medical association decided not to
take any further action at the moment.
Due to the different methods (case 1: prototyping;
case 2: survey) and research foci (case 1: organiza-
tional barriers of e-appointment implementation;
case 2: organizational readiness for e-appointment
implementation), the inquiries in the two cases re-
vealed different aspects of organizational difficulties
in relation to introducing e-appointment in a given
environment. However, most of these aspects are
likely to impact the e-appointment implementation
decisions in any given environment, respectively. At
the end, the benefits of e-appointment implementa-
tion must outweigh the cost of service development
and of resolving all the organizational problems
associated to this endeavor. In both cases reported
here, the main actors (the city administration, the
medical association) were basically willing to take
responsibility for introducing e-appointment, but the
objections they had been facing amounted too high
from their point of view. Similar objections could be
traced in any other organization or network, and it is
likely that for the time being in most cases the
economy of scale is not in favor of e-appointment
implementation.
6. Conclusion
In this research we studied two strategic efforts of
implementing e-appointment in a given environment.
It turned out that the main challenges on the road to
successful e-appointment are a detailed under-
standing and modeling of the appointment-making
process, a technical infrastructure which enables
communication between distributed software
components, and organizational circumstances and
requirements for IT support which do not spoil the
economy of scale. The problems encountered in
these two cases are likely to be faced by other efforts
which seek to set up a centralized e-appointment
service for a large organization or organizational
network. To conclude: what can we learn from these
inquiries for future research and practice aiming at
making e-appointment a beneficial service for all
actors involved?
From the systems development point of view
distinguishing different phases and types of the e-
appointment process has helped to identify and
model the activities within an e-appointment process
and to understand the users requirements in
sufficient detail. However, if the application environ-
ment is technically and organizationally dispersed,
the development of a Web-based service component
must take precautions in order to avoid project
failure: On the infrastructure level it requires
standardized access to calendar data, an overall
policy and implementation of secure data transfer, a
gateway (including routing function) relating the
front end application with backend data bases, and an
organizational responsibility to set up and operate the
gateway and front end application. On the
application level the types of appointment-making
processes and the types of appointments (purpose,
length, etc.) to be supported must be limited to a
manageable number in order to prevent high
development costs and to maintain usability.
From the organizational point of view 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.

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