Using Technology to Reduce Missed Appointments

Abstract

Purpose:  To present an integrative review of the use of messaging systems on reducing missed appointments in an ambulatory setting.

Background:  The recent introduction of technology into ambulatory settings has expanded the capabilities of communication with patients.  Missed appointments (no shows) are a significant problem facing clinical practices. It can cause disruption in clinical services as well as affect the continuity of care for patients and caregivers. For clinicians, missed appointments often means reduced revenue and wasted resources, however, recent changes in technology offers a potential way to reduce expenditures and improve patient compliance with appointments.

Material and Methods: In this study, an integrative review of the literature was used. The search strategy began with two electronic databases (CINAHL and Pubmed). Considering the inclusion criteria, published studies that examined the factors influencing missed appointments, electronic health records, and messaging reminders for the last 10 years was chosen. Data extraction and analysis were completed on all included studies. The final sample for this integrative review comprised 20 studies.

Conclusions:  This review revealed that notification systems help reduce missed appointment significantly.  Many studies produced a 5 -10% decrease in the missed appointment rates.  The mode of the notification systems will vary by community and patient population. All notification systems appear to produce the similar results.  Future research should be directed to examine the effect of timing messages on reducing the missed appointments.

Background

Missed appointments (no shows) are a significant problem facing clinical practices. It can cause disruption in clinical services as well as affect the continuity of care for patients and caregivers. For clinicians, missed appointments can interfere with adequate medical care, misspend administrative and medical resources, and are associated with adverse patient health outcomes (Perron et al., 2013).   According to Tine Health (2018), a significant number of missed appointments can equate to millions of dollars in lost revenue, especially in a hospital setting.  A 2016 study of the effects of missed appointments demonstrated that the average yearly no-show rate for primary care and specialty medical appointments is just under 20 percent — an astounding number that could mean significant revenue loss for healthcare systems, both large and small (Tine Health, 2018).  The causes of missed appointments may vary between medical specialties and patient population.   Reducing the number of missed healthcare appointment improves the efficiency of health services (Robotham et al., 2016), which also can potentially impact business revenue. 
The potential impact of missed appointments has both financial and clinical relevance, therefore it will behoove the healthcare industry to limit this phenomenon.  Over the last decade, multiple studies have been performed to help identify ways to reduce missed appointments.  Many studies have reviewed various modalities which are used to achieve this.  These include (but are not limited to) phone reminder systems, short messaging systems, and reminder letters. These strategies have been found to reduce the number of missed appointment occurrences in various ambulatory settings, including laboratory and clinical follow-up care. 

Literature Review

A comprehensive literature review was performed to identify the applicable research studies that have demonstrated the effects of notification systems on missed appointment rates.  The literature on the effects of notification systems on missed appointments is limited.  The search terms were expanded to include a broader terminology in addition to the smaller more specific terms (see Table 1, for search terms used in the literature review).

Table 1: Key Search Terms for the effects of Messaging Systems on Missed Appointments

In order to better understand the current work on missed appointments, a PubMed search was performed in March 2018 using the Boolean search ((((((("Electronic Health Records"[Mesh] OR "Electronic Health Records"[Title/Abstract]) OR "Electronic Health Record"[Title/Abstract]) OR "EHR"[Title/Abstract]) OR "electronic medical record"[Title/Abstract]) OR "electronic medical records"[Title/Abstract]) OR EMR[Title/Abstract]) AND ((((((("Cell Phone"[Mesh] OR "Cell Phone"[Title/Abstract]) OR "Cell Phones"[Title/Abstract]) OR "Cellular Telephone"[Title/Abstract]) OR "Cellular Telephones"[Title/Abstract]) OR "Mobile Phone"[Title/Abstract]) OR "Mobile Phones"[Title/Abstract]) OR (((("Telephone"[Mesh] OR "Telephone"[Title/Abstract]) OR "Telephones"[Title/Abstract]) OR "Phone"[Title/Abstract]) OR "Phones"[Title/Abstract]))) AND (((((((("Appointments and Schedules"[Mesh] OR Appointments[Title/Abstract]) OR Appointment[Title/Abstract]) OR Schedules[Title/Abstract]) OR Schedule[Title/Abstract]) OR "Patient Schedule"[Title/Abstract]) OR "Patient Schedules"[Title/Abstract]) OR "Patient Appointment"[Title/Abstract]) OR "Patient Appointments"[Title/Abstract]) with filters placed for publications from the past 10 years.  Articles were further restricted to randomized clinical trials and review articles.

The CINHAL database was searched next using the Boolean term ((“ missed appointment” or “no show”  AND “Absenteeism”))  ( “primary care “ OR “ambulatory clinic”) and (“notification systems” OR “nudge” OR “phone” AND “phone calls”) OR (“Short Message”AND”Real time notification system”) OR (“scheduled appointments” AND” Absenteeism”) OR (“mobile phone messaging reminders” OR ( “text message reminders” ) AND (“ phone call reminders”) AND (“reducing missed appointments”).  This search yielded about 20 results.  Many items were eliminated because of the age of the article or its irrelevance to what was being studied.

From the searches listed above the it was concluded that a certain number of missed appointments was related to patient forgetfulness.  This review will focus on appointment reminders and their ability to reduce the overall missed appointment rate in ambulatory treatment clinics.

Inclusion / Exclusion Criteria

After focusing on specific terminology, the following criteria was applied to the research articles. The inclusion criteria for the research articles are listed as follows: 1) research five years old or newer, 2) articles which focused on appointments in ambulatory treatment centers, and 3) research that used commonly used notifications systems (such as text messaging, phone calls, and appointment cards).  Of note, this inclusion criteria were expanded after the initial search due to the limited availability of articles. The exclusion criteria for the selection of articles includes articles that are older than five years, articles that focus on tumor progression (which is not being studied), animal studies were excluded, and studies not addressing the concept being studied.  The final total for the selected articles was 15 (see Figure 1, for the Prisma diagram for this quality study).

Figure 1: PRISMA 2009 Flow Diagram

A large percentage of the articles clearly illustrated the effects notifications systems have on missed appointments in ambulatory clinics. Many of the studies presented demonstrate that reminders systems are an effective route to reducing missed appointment or no-shows. 

Article Synthesis

The cause of missed appointments can be multifactorial and complex.  Understanding missed appointments can be a quest, as illustrated in a study by Aggarwal et al., (2016).  The authors of this study attempted to understand if implementing policies such as those believed to affect social justice or cost would affect nonattendance rates. It unfortunately only yielded modest results. One could search endlessly for the reason or causes of missed appointments. Therefore, in order to better conduct a quality appraisal, the review of literature was narrowed to focus on a common cause of missed appointment - Forgetfulness.  The review was refined to focus on results that can be used to conclude, that in the case of forgetfulness, appointment reminders systems may be an effective way to increase the health care systems revenue and to also improve continuity of care among patients by reducing missed appointments.

Many studies have demonstrated that various reminders can improve the missed appointment rate.  For example, in a study by Parikh et al., (2010), the no show rates improved for patients that received phone calls from staff members. This study demonstrated a rate of 13.6% for staff reminders versus a rate of 17.3% for patients that received no reminders at all. Another study by Shah et al. (2016), showed that a telephone reminder placed seven days before the scheduled visit led to a decrease of missed appointments by 22%.  These are excellent examples of how notification systems may be used to reduce missed appointments. A similar study by Perron et al. (2015) showed very similar rates in patients receiving text message reminders and phone call reminders which would appear that both are feasible.  However, other studies such as Kheirkhah et al., (2013) only showed a modest reduction in missed appointment rate with a phone notification system and/or phone call versus text message systems.  This may demonstrate that a phone call notification system may not be an economically sound intervention for many health businesses to reduce missed appointment rates. This type of system can possibly over burden staff with phone calls that may not yield economic benefits.

Now with technological advancements, phone call notifications systems or staff notification may not be the most cost-effective way to reduce missed appointments.  Technology has evolved in such a way that the use of short messaging systems can be safely applied to health care settings to communicate information to patients.  Ingersoll et al. (2015), studied the use of bidirectional messaging and found that this type of communication was useful in improving medication adherence rates and reducing the number of missed appointments.  A similar result was found in a study by Christopoulus et al., (2014) which used text message blasts to encourage HIV patients to adhere to medication regimens and return for follow-up visits. A study done by Som et al. (2017) yielded positive results with the implementation of short messaging systems into its health care business and not only reduced missed appointments but hospital admittance.

Text message communication can used in scheduling and/or appointment reminders as well.  Randomized control trials have been done which demonstrated the positive outcomes of using text message reminders on reducing missed appointment rates.  Studies such as Arora et al. (2015), Liu et al. (2017), McInnes et al. (2014) demonstrated a significant difference in the missed appointment rate of patients that received text- message reminders. Whereas a study by Percac-Lima (2016), showed little reduction in missed appointments which was considered not statistically significant. 

Table 2 shows the evidence and synthesis tables of the above reviewed research articles. 

Table 2 (has 4 parts): Effects of Messaging Systems on Attendance Rates in Ambulatory Clinics

Strength and Limitation of Review

Strengths

This type of review aimed to examine the use of EMR system notifications versus phone call notifications has not been attempted at this time.  A review of this type can provide insightful changes to health care systems nationwide and help reduce the number of missed appointments.  It is possible that it could fill some research gaps in knowledge about the effectiveness of notifications systems.  Since electronic medical systems are becoming the norm in health care, this research could be the basis for designing user friendly systems and notifications thereby reducing no show rates.  It may eventually have a scheduling feature that would be more user friendly to patients and their families. The review in its current form complements previous research and begins to incorporate research of newer technology into old patient care problems (i.e. missed appointments). The review contributes to providing better understanding on how integrated notifications systems can impact patient care and provides a model for reducing the rate of missed appointments.

Limitations

Yet, while there are some strengths of the review as mentioned, in its current form it may be inadequate.  Several of the review articles were on a high-risk population such as mental health patients or HIV patients. This may skew results as these patients have a higher than normal missed appointment rate. The most pertinent limitation is the lack of research in this area which may make the results appear invalid.  Although the findings have the potential to financially impact the health care system, little data is available to use in a literature review.  More studies will be needed to reproduce findings of previous studies in notification systems.

While this review is valid today, it may be quickly outdated because of advancing technology. Technology is evolving daily, and system applications are routinely updated. This could quickly lead to outdated research findings.   Also, findings may not always be able to be generalized because not all health care systems will have the same technological resources available for consumer use.  Many notifications systems differ and may not fit neatly into one category.  Another limitation is that data collection may remain costly thereby limiting research funding in this area.  However, if health care systems could realize the potential benefit of reducing the missed appointment rate, it may be worth the investment.

A final limitation is that the review is not well balanced and has more information on text messaging systems than other notification systems.  This is a limit to the accuracy of the results.  Also, the review does not demonstrate that missed appointments are usually multifactorial and cannot be limited to forgetfulness.  Several sources mention that missed appointments can be related to forgetfulness but they are also sometimes related to factors such as transportation issues, family issues, or cost.

Conclusion

The purpose of this review was to understand the research trends in notification systems and their influence on missed appointments in the last five years. A review of the articles presented in this review, revealed that notification systems help reduce missed appointment significantly.  Many studies produced a 5 -10% decrease in the missed appointment rates.  All notification systems appear to produce similar results. It is evident that the trends in notification systems can vary by community and patient population focus.  It is also clear that the area of notification systems is evolving rapidly, and that research today may be obsolete in a few years.
Recommendations for future research should focus on better use of EMR notification systems to give real time updates on patient systems or provide self - scheduling applications which would more likely reduce the missed appointment rates. The use of EMR notifications versus phone call notifications is still being studied but it is evident that missed appointments can be detrimental to the health care system as well as the patient. This area of inquiry is very pertinent and has at its center, a concern for patients and the financial stability of the health system.