Centralized Appointment Scheduling:

Industry Leading Access to Primary Care Services

American College of Medical Practice Executives Professional Paper

- FOCUS PAPER -

Paper being submitted in partial fulfillment of the requirements for election

to Fellow

1

Focus Paper Title – Centralized Appointment Scheduling: Industry Leading Access to Primary Care Services

Introduction

The purpose of this paper is to discuss the need for healthcare organizations or systems

to adopt or refine centralized appointment scheduling for primary care services to assist

in providing greater access for patients. Independent healthcare providers are

integrating their operations into health systems unlike any time in the past and it’s easy

for this integration activity to distract from key operational issues. Ensuring efficient

operations is paramount in today’s healthcare environment, considering continual

reimbursement pressures on operating margins as well as patients’ expectations of

service being provided without delay. The front door to any health system is through

primary care services and, whether one is new to the community or a long-time health

system user in the community, the first point of contact that patients have with primary

care is often over the phone. More than ever before, it is critical to offer new primary

care patients and returning patients an experience over the phone, which is

dependable, timely, and patient-centric. This experience can be achieved through

appointment scheduling by phone that is offered in a centralized fashion and

transparent to patients. Additionally, this work must be surrounded by a health system

that embraces a standardized approach in how services are offered so that patients

receive a consistent positive experience that meets and exceeds expectations regardless

of location.

2

Overall objective of this paper

a. Focus

The author of this paper has researched best practices in the management of

primary care patient appointment scheduling within health systems

interested in providing greater patient access. A few decades of direct

industry knowledge and first-hand experience will be offered in this paper.

b. Purpose

The ideas presented in this paper will provide suggested approaches to

address patients’ appointment needs and to monitor related outcomes, in a

timely and cost-efficient manner. It will be suggested that by using an

approach of organizing centralized primary care appointment scheduling

systems, there would be an improvement in efficiency and a minimizing of

expenses. According to Moody’s Investors Service, the median annual

expense growth rate in 2016 was 7.1% compared to the median annual

revenue growth rate of 6.1%, a difference of 1.0%. The negative margin

between expenses and revenues increased even more in 2017 with expenses

growing at 5.7% compared to revenue at 4.6%, a difference of 1.1%

(Sanborn, 2018). Similar projections were expected throughout 2019 with

expenses anticipated to end in the range of 4 to 5% and revenues anticipated

in the range of 3 to 4% (Kacik, 2018) concluding, that health systems which

fail to standardize and consolidate operations will be left behind in a

healthcare environment in which expense growth outpaces revenue growth.

3

c. Situation being analyzed

The traditional medical practice environment has team members who check-

in and check-out patients to and from their medical appointments while

simultaneously answering incoming phone calls and making outbound phone

calls. Alternatively, they might have individuals who are separated from this

front-office activity to answer phone calls to schedule patient appointments

and to address other patient issues over the phone. In many cases, this

phone activity may only have one or two individuals assigned to it. Phones,

check-in lines, check-out lines, and team members can easily get backed up

and patients quickly become irritated and frustrated with apparently

inefficient service. Add to these challenges a team member who calls off sick

and suddenly one-third or half of the front office team is unavailable, and the

concerns have escalated. While this represents the challenges of one

medical practice location, increasing the number of locations only adds to

the potential for ineffective operations as well as patient confusion due to

multiple phone numbers and departments.

What will be covered in this paper?

First, an analysis and discussion will be presented about current health

system approaches to scheduling primary care patient appointments. With

this information in hand and having the goal of maximizing patient

satisfaction and minimizing cost, alternative approaches for organizing

primary care appointment scheduling centers will be presented along with

4

possible outcomes that health systems could expect. Appointment

scheduling centers are not to be confused with call centers which handle

every type of incoming call, regardless of reason. This paper will conclude

with a discussion about the approaches to primary care appointment

scheduling and the significance of the findings.

How will the key topic be addressed?

The primary issue at hand is identifying how health industry leaders can best

meet the ever-increasing needs and expectations of patients, who want to

minimize the time they wait for services, and still achieve financial and

operational goals. The key topic being addressed in this paper is meeting

these needs and expectations through cost-efficient and effective scheduling

of primary care medical appointments. This will be addressed by analyzing

current approaches and outcomes and comparing these to other methods of

organizing team members to achieve positive results with patients, while

minimizing health system costs.

Explanation of the research methodology used

a. Literature search

Many health systems have attempted to address the issue of scheduling

timely primary care medical appointments in a patient-centric manner. As

such, numerous articles and perspectives were taken into consideration

while comparing approaches, to discover best practice models. While there

is much discussion in the industry on this topic, it was somewhat surprising

5

to discover that there is not much in the way of standardized or

benchmarkable metrics. There are many individual health systems and

studies that present data in their own non-standardized way however, there

is not an industry-wide common view for this information.

b. Interviews

Individual interviews and discussions, as well as group discussions and

analysis, were conducted on a limited basis to inform the methods presented

in this paper. Individual practice managers, practice directors, physicians,

medical directors and patients were queried for their perspectives on the

advantages and disadvantages of patient scheduling environments, and the

benefits and shortfalls of each.

c. Experience

The author of this paper contributes over 30 years of health industry

experience which has included the implementation and use of various

methods of patient appointment scheduling. In evaluating these methods,

consideration was given to the needs, desires and input of patients who seek

responsive services, providers who want to maximize quality and

productivity, and team members who listen to patients and know first-hand

about their challenges and concerns. Because of the author’s career

involvement with patient scheduling within a few health systems, more

emphasis was placed on the research methodology of experience, as

compared to interviews.

6

Background/Context

Importance of patient access to care

Difficulties with access and long wait times are associated with negative

patient outcomes. Patients who have experienced long wait times, even for

non-urgent needs, have been shown to have higher rates of noncompliance

and appointment no-shows. According the Vitals Index, 84% of patients

believe that wait time is either somewhat important or very important to the

overall experience at a doctor’s office. In fact, 30% of patients have walked

out before being seen due to long wait times and 1 in 5 patients report that

they have changed doctors because of long wait times. (Business Wire,

2018). This represents not only an increase in costs to patients’ care but also

a lost service opportunity for the providers of care. Additionally, it is

apparent that inefficiencies in healthcare processes result in lower levels of

patient satisfaction and contribute to provider dissatisfaction and burnout, a

growing concern in healthcare that is partly the result of these inefficiencies.

The role of patient appointment scheduling in providing patient access to care

One of the most critical aspects about patient appointment scheduling is that

it must be surrounded by standard provider templates and scheduling

guidelines. Recognizing this allows for consistency of experience for patients,

for improved scheduling accuracy, for reduced call wait times, and for a

simplified process for patients who are selecting new providers. Each of

these factors allows patients to feel that getting access to a new provider or

7

their existing provider is simple and convenient. Having a larger pool of

scheduling staff for multiple practices allows for better absorption of the

ebbs and flows in call volume that individual practices may experience, and

this results in improved speed to answer calls, reduction in call abandonment

rates due to shorter call answer times, and better overall service levels.

It is reported that 80% of medical groups are working to improve patient

access in some way. However, the data suggests that groups are still failing

to meet some critical patient demands for access. Specifically, two

accessibility-related demands are not being consistently met: (1) extended

office hours and (2) centralized scheduling services. (Advisory Board, 2018).

Models used to schedule patient appointments

The traditional independent medical practice, as well as many health systems

with expanding medical practices and sites of care, employ medical

receptionists that are responsible for both the check-in and check-out of

patients and the answering of phones which includes scheduling of patient

appointments. Alternatively, grouping medical practice sites of care, in order

to offer centralized appointment scheduling, is an ongoing trend that allows

for much greater operational efficiency, better patient access to their

providers, and flexibility in operations. Variations are also possible in the

way that practice types are grouped together (e.g. primary care, surgical,

specialty, therapies, etc.) or the way in which geographical locations are

grouped together. Having one physical location is not necessarily the best

8

answer since other issues need to be considered. These issues include

redundancy that is needed for system outages or site emergencies, backup

support for times of excess volume, the pool of candidates who qualify for

these positions of employment in a specific geographical area, and even

office space constraints. With these issues in mind, two or more “scheduling

hubs” have proven to be very beneficial for health systems.

While the focus in this paper is on phone appointment scheduling, other

options include on-line appointment scheduling and in-person appointment

scheduling. Additionally, open scheduling for new patients, in which these

individuals can obtain access to appointments either through the health

system’s on-line scheduling or through independent vendors, can provide

similar on-line access to appointments.

Standard work that impacts the patient scheduling process

If patients find it difficult to locate the phone number of a primary care

medical practice, they will often move on to the next provider in the area,

due to lack of convenience. Having one phone number for all health system

primary care locations allows patients to quickly identify with the health

system. From there, the appointment schedulers can assist in finding the

best provider for the patient throughout the various sites of care. Another

area of standardization which impacts patients would be the steps the

patient goes through on each call, allowing them consistency with their

provider of care. With standardized scripting and workflows in patient

9

scheduling, the patients begin to learn the order of questions, regardless of

the individual scheduler who is helping them, and they become better

prepared with the answers and information. The accuracy of scheduling

should improve with the same team members having responsibility for the

scheduling function. Versus the inefficient decentralized environment in

which team members may have to be temporarily pulled from other

responsibilities when a scheduler is gone, or heavy call volume requires the

additional help. In these cases, the lack of knowledge and experience

negatively impacts accuracy. Additionally, minimizing the choice amongst

visit types in the electronic health record (EHR) allows for ease of selection

by the scheduler and reduction of errors by providers and team members

due to the multitude of visit types being properly identified and scheduled.

This author is aware of health systems that only allow for two visit types in

the EHR – a short visit and a long visit - while others have literally hundreds

of visit types available for team members to choose. Lastly, having one

supervisor or manager responsible for all appointment scheduling activities,

regardless of number of “scheduling hubs”, will help drive the desired

consistency and standardization for the health system.

Review of key stakeholders

There are many stakeholders that have a part in maximizing the appointment

scheduling experience for patients. Besides the patient being the chief

stakeholder, other stakeholders include physicians, advanced practice

10

providers (APPs), practice managers, medical receptionists, medical

assistants, registered nurses, triage staff, senior administrators and more.

In any health system review, most often it is the patient that gets forgotten

when it comes to pulling together key stakeholders. It is assumed that we

are all patients and have the best perspective of our patients in mind.

However, health care workers tend to forget that they approach problems

and solutions with their employee “hat” on which will inevitably bias their

perspective on what is best for the patient.

The other stakeholders that are often left on the sidelines are the physicians

and APPs. They are often viewed as being too busy and that caution should

be taken to include them because of patient care responsibilities and

concerns with lost productivity and revenue. It is extremely imperative that

they are well represented at the table, especially considering the need to

establish consistent and standardized scheduling guidelines and provider

templates.

Another important stakeholder(s) is health system senior administration. At

a bare minimum, there should be one senior administration champion who

stands behind the initiative and who can routinely provide updates to others

in administration. Without this support, the importance and urgency of the

work will not be recognized.

Practice managers and directors will likely handle the greatest share of work

to be done in leading information gathering, provider preferences for

11

scheduling, provider template rebuilding, staff education, patient

communication, and more. These individuals are the conduit of

communication and are pivotal in guiding the initiative forward and are

absolutely pivotal to its success or failure.

Lastly, and certainly not least, is the input and involvement of clinical support

staff team members. The breadth of this representation will be beneficial by

incorporating individuals such as nurse assistants, medical assistants, medical

receptionists, nurses, social workers and others.

In the end, having a representative cross-section of individuals, that is of a

reasonable and manageable size to serve on a steering committee, will help

lead the initiative forward. The number of stakeholders that can provide

input can be unlimited however, the committee should consist of no more

than 7 to 10 individuals. Keeping to this size allows for a finite number of

opinions and perspectives which are well respected by others in the health

system.

Body of the Focus Paper

Key considerations

There are many factors to consider when transitioning to a centralized

appointment scheduling system. First and foremost, one must engage with a

cross-section of the key stakeholders who are most willing to think about

things differently, who are open to change, and who want to do what is best

for the health system and its patients. It will also be valuable to include

12

some who may resist change, in order to consider all perspectives and to gain

insight from the “devil’s advocate”. Second, key appointment scheduling

team members will have the greatest level of knowledge when it comes to

what patients like or do not like. Third, it will be beneficial to understand

how others in the industry operate and what we can learn from them. While

it is difficult to find a consistent set of industry benchmarks for centralized

appointment centers, there is enough data available that can give a sense on

whether one is moving in the right direction. In the end, the best way to

measure is against your own health system trends and to incrementally

improve upon these results, in areas where there is a sense of opportunity.

There are so many variables that each health system must navigate, and no

two health systems are alike. So, knowing your own trends over the course

of time and how your current performance compares to the past will give the

best indication of how well one is doing. Some common things to measure,

in no specific order, include average number of seconds to answer, service

level percentage, percentage of calls converted to appointments, call

abandonment rate, percentage of calls handled, call duration/handle time in

minutes and seconds, scheduler quality score, and patient satisfaction.

Effective approaches to patient appointment scheduling

As discussed earlier, grouping medical practices and offering centralized

appointment scheduling is an efficient and effective approach that offers

greater access within a more cost sensitive model. There can be variations in

13

how this centralized approach is handled, considering the nuances of each

health system. Thinking about the geography of medical practices, health

systems may find it beneficial to group practices by type (e.g. primary care,

surgical, specialty, therapies, etc.) or by geography, to take advantage of

common knowledge or of local labor pools, especially if the population base

is largely rural. Health systems must always consider other aspects, such as

system redundancy. What happens if a natural disaster hits the area or if a

section of the electrical power grid in the area is disabled for hours or even a

couple of days? How then are these calls being answered when the primary

care medical practice doors are still open for business? Therefore,

consideration should be given to having more than one physical location with

the capability to have calls immediately migrate to the other location if there

is an outage. As a health system is considering the possible transition to

centralized appointment scheduling, one extremely important aspect to

consider is the roll out of the implementation. The author of this paper and

others feel strongly about staggering the implementation to the central

location with one clinic location at a time. Allowing at least three or four

weeks in between each clinic location implementation is not unusual and

allows for several benefits including immediate feedback specific to the

nuances of each clinic, an opportunity to adjust or change workflow based on

lessons learned, a chance to pause the implementation for other clinics if a

14

significant challenge needs to be addressed, and time for team members at

each clinic to adapt to the centralized workflow.

Alternative approaches and methods

In our age of technology, there is clearly a move towards increased use of on-

line appointment scheduling. This author is aware of actual data that the top

10% performers in 2017, who were using the industry leading EHR, were

seeing on-line appointment use at a rate of 2.4%. Data available in 2019

indicated that this top 10% performing group was seeing on-line

appointments at 4.8%. While this is not a significant shift, it is relatively clear

that this trend will continue in the direction of increased use, and ongoing

efforts to allow patients this type of access is certainly increasing. While this

may appear at the surface to relieve health systems from the intensity of

appointment scheduling, it must recognize that these appointments have to

be carefully monitored and managed, often with every appointment being

validated for accuracy. The resulting corrections may require additional

phone calls to patients to clarify needs or to schedule a different

appointment time, depending on the type of error that occurred.

Another approach allowing greater patient access is called open scheduling.

This approach takes the scheduling challenges one step further allowing not

only established patients to schedule appointments but also new patients

who have never seen a primary care provider within the health system.

Again, the types of appointments that patients can choose must be carefully

15

monitored and managed, in order to reduce scheduling errors. A health

system may have the best design that controls and guides patients into the

most appropriate scheduling slots however, errors will still occur.

This author is also aware of a health system which uses an approach called

wave scheduling. With this approach, all patients are scheduled at the top of

the hour so that partway through the hour you know if you will have no-

shows. If there is an open patient slot available, a provider then knows they

can see a walk-in or urgent patient need. The hope with this approach is to

help the provider, who might have patients with a lot of same day needs, to

better manage their patient panel. There is a variation to this wave

scheduling approach which is called modified wave scheduling. The concept

with this approach is generally the same and the main difference is that only

two or three patients are scheduled at the top of the hour and additional

patients are scattered throughout the hour, again with the understanding

that there is likelihood for a higher than normal no-show rate, typically found

in a lower-income population.

Review of process

Maximizing efficiency in key areas can make a significant impact on the

performance of any health system. Take, for example, a health system that

historically had a call duration of 4 minutes and 30 seconds. It handles

15,000 calls each month, resulting in 67,500 minutes of phone time per

month or 1125 hours. Through process improvement, standardization, and

16

centralization, this same health system finds itself managing each call in an

average of 3 minutes and 30 seconds. Upon further review, this health

system recognizes that it has shaved 250 hours of talk time per month,

representing about 1.5 full time equivalents (FTEs)! Double the number of

calls in this example for a larger health system and the staff savings could

represent 3 FTEs.

If an organization is considering implementation of a centralized group, the

team must provide high quality services with knowledge and expertise right

from the start. In the absence of this type of implementation, the confidence

of the patients and physicians will quickly deteriorate, and they will want

their prior scheduling system restored. Additionally, clinics which are yet to

be integrated with the health system will strongly resist joining the new

appointment system structure, making it extremely difficult to have a

successful path forward.

Expected outcomes

There are specific outcomes that each health system needs to measure in

order to understand the impact of its work and the impact of incremental

changes that it chooses to make, whether through lean or kaizen

approaches, to improve the workflow. While industry benchmarks can be

found, they are not broadly accepted and adopted, although they do provide

a sense for whether a health system is moving in the right direction. Without

a doubt, the best measure of success is through an evaluation of internal

17

trend data while understanding the impact of individual changes. Having

said this, some of the most important elements to measure include:

a. Average time to answer: The ways to measure this in the industry

vary including an overall average or a percentage answered within

so many seconds; typical benchmarks noted with this research

include average time to answer of 50 seconds or less, with best

performers answering 90% of their calls within 20 seconds.

b. Call abandonment rate: For clarification, the abandonment rate is

the percentage of inbound phone calls made to an appointment

center that are abandoned by the patient before speaking to a

team member and it is calculated as abandoned calls divided by

total inbound calls. Abandon rates have a direct relation to

waiting times. Typical goals for this category are less than 4% and

best performers are less than 2%, although some of the data

suggests that less than 4% is a best performer.

c. Call duration / handle time: Often less than 3 minutes and 30

seconds with best performers closer to 3 minutes.

d. Patient satisfaction: While the type of question will help

determine the percentage, achieving satisfaction rates of 95% or

higher are clearly industry best, while the average performer

hopes to exceed 80%.

18

The author of this paper suggests the chart of metrics below as a starting

point for industry standard benchmarking, with the hopes that health

systems will align, adopt, and compare in the realm of these common

metrics. Having said this, nothing will ever replace the ability for a health

system to benchmark against its own historical performance. Consider the

following as measurements to be adopted by others, to move towards this

more standardized industry perspective:

Discussion

As reimbursement pressures continue to increase, health systems must

continue to find ways to become more efficient. Additionally, health systems

must find ways to meet the patient where they are and be patient centric.

The patients of the decade 2000 are no longer the patients of the decade

2020 and people are not willing to wait. Health systems that meet and

exceed these patients’ needs will increase patient loyalty and will succeed in

19

the competitive healthcare environment. Technology will continue to

advance and alternative ways to monitor one’s health and to communicate

with healthcare providers will evolve. Keeping abreast of these technological

advancements will be important however, the author of this paper expects

most patients to rely on the long-standing approach of scheduling medical

appointments by using the telephone and talking directly to their health

system of choice. The basis for this prediction is that on-line appointment

scheduling has been available to patients for several years, yet the adoption

rate has experienced relatively slow growth.

Significance of the findings

a. So, what does this mean?

It means that health systems must answer their phones more promptly, it

means that key details about the patient must be understood in a timely

fashion and known into the future, it means that the time patients spend on

the phone must be kept to a minimum, and all of this means that patients

will ultimately be more pleased with the care they receive.

b. What if nothing was done?

Solutions in healthcare are not “one size fits all” and the author of this paper

is not advocating that centralizing appointment scheduling in primary care is

the best and only solution for every health system. Maintaining

decentralized, independent appointment scheduling locations can be

successful, when the patient is kept at the center of the approach. Having a

20

couple of star-employees can have a very positive impact on the perception

and satisfaction that patients have about their experience and it can be

difficult to duplicate a personalized level of service within a centralized

environment, especially as the number of team members grows. Having said

this, it is likely difficult to gain the desired level of system standardization and

efficiencies within a decentralized approach, and the cost savings

opportunities that are missed must be made up in other ways. As discussed

earlier, health systems with expense growth outpacing revenue growth must

find every way that they can to maximize the efficiency of its work.

Additionally, if a health system maintains a decentralized approach,

consideration should be given for how peak volume of phone calls will be

handled when there are limited team members who can flex with the

demands. Perhaps other team members should be cross trained to provide

back-up support for this work or maybe other sites of care can serve as

support for call volume overflow.

c. Summary of what others may learn.

Technology seems to have no boundary, and this leaves the door open for

other advances in service to patients for years to come. Emerging models of

care means that healthcare will continue to evolve and be delivered in ways

never imagined and we must remain flexible in our approaches. As the

author of this paper was “penning” the finishing touches, COVID-19 was

ramping up in the United States. Who would have thought that our globe

21

would have experienced such a crisis! So, what is the point about this? Well,

how does this change our world and how do events of the future change our

world, in ways that we never thought? How much will the COVID-19 crisis

change the way we care for patients and distance ourselves socially from

others? What then can be expected when it comes to expanding virtual

patient visits including video, telephonic and electronic health record

messaging? And as patients become more comfortable with technology in

healthcare, how will this change the ways in which patients communicate

with their healthcare provider, including scheduling of appointments? Will

more health systems shift towards a portion of the labor pool working from

home? We have seen home-based positions in the areas of billing and

coding however, it has not seemed to shift much to other disciplines.

Significant events certainly have and will place a new and different

perspective on the entire healthcare landscape. Throughout it all, and never

ending, will be the fact that the patient remains at the center, with ever

increasing demands and expectations.

d. Areas for further research.

The focus of this paper has been on primary care appointment scheduling.

Areas for continued growth and learning include specialty care, surgical care,

radiology, lab, and rehab appointment scheduling. And while primary care

appointment scheduling has been at the center of this paper, additional

research needs to be conducted on best practices relative to the possible

22

centralization of referral coordination, of prior authorizations, of medication

refills, of triage services and more. Also, as referenced earlier in this paper,

on-line appointment scheduling has not gained adequate following to allow

the industry enough experience with this modality. Further understanding

and research will be beneficial for development of this approach.

Final Comments

There are many “front doors” to a health system and each one can have a significant

impact on its success. Meeting and exceeding the needs and expectations of patients is

critical in the competitive healthcare environment in which we live and must be done

with efficient operations in a time when operating margins are narrowing or

disappearing. Since one of the front doors is through primary care services, and a front

door to primary care is through its answering of phones and having simple and available

appointment solutions, the structure of these operations is extremely important to the

patients’ experience. Providing these patients with a consistent, standardized, and

positive interaction with team members will go a long way in securing their confidence

and loyalty. There are many aspects to consider when organizing primary care

centralized appointment scheduling in a health system, and there are many benefits and

advantages to establishing this centralized structure. While there are complexities to

this model, a well planned and collaborative approach will lend to the success of these

services and the success of the health system.

23

Bibliography

Advisory Board. (2016). 10 Steps to Centralized Scheduling. Washington D.C.: Advisory Board.

Advisory Board. (2018). Five Must-Have Characteristics of the Consumer-Focused Physician.

Washington D.C.: Advisory Board.

AHC Media. (2013). Switch to centralized scheduling. Atlanta: AHC Media.

Association, A. M. (2014). One Destination, Two Journeys: Call Center Centralization at Henry

Ford Medical Group and The Jackson Clinic. Alexandria: American Medical Group Association.

Brandenburg, G. S. (2015). Innovation and Best Practices in Health Care Scheduling. Washington

D.C.: Institute of Medicine of the National Academes.

Business Wire. (2018). 9th Annual Vitals Wait Time Report Released. New York: Business Wire.

Chan, T. (2014). How Aurora Medical Group reinvented the scheduling wheel. Washington D.C.:

Advisory Board.

Creech, M. D. (2017). Save money and reduce stress with centralized scheduling in healthcare.

Chicago: Becker's Hospital Review.

Heath, S. (2017). Centralized Appointment Scheduling Aids Patient Experience. Danvers: Patient

EngagementHIT.

Institute for Healthcare Improvement. (n.d.). Reduce Scheduling Complexity. Boston: Institute

for Healthcare Improvement.

Kacik, A. (2018). Not-for-profit hospital expenses will continue to outpace revenue in 2019.

Chicago: Modern Healthcare.

Krim, T. (2012). Leading Trends in Patient Access. Beverly Hills: American Health Connection.

Kumar, S. S. (2014). Healthcare Systems and Services Practice - The access imperative. New York

City: McKinsey & Company.

Relate Care. (2016). The Centralization of Primary Care Scheduling. Cleveland: Relate Care.

Sanborn, B. J. (2018). Moody's data shows expenses continue to outpace revenue for nonprofit

hospitals. Healthcare Finance.

Wilkins, A. (2018). A Review of Centralized Scheduling Implementation in Pediatric Ambulatory

Care.

Williams, M. (2015). Online Appointment Scheduling Expected to Increase in Healthcare.

Horsham: VAR insights.