See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/249643353

DEVELOPING AN ONLINE PATIENT APPOINTMENT SCHEDULING SYSTEM

BASED ON WEB SERVICES ARCHITECTURE

Conference Paper · October 2012

CITATIONS READS

6 11,188

5 authors, including:

Xiaojun Zhang Ping Yu

Chinese Academy of Sciences University of Wollongong
6 PUBLICATIONS   109 CITATIONS    167 PUBLICATIONS   1,652 CITATIONS   

SEE PROFILE SEE PROFILE

Jun Yan
Microsoft
161 PUBLICATIONS   2,949 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

‘Pre-habilitation’: technology-based schemes for lifestyle management in the pre-operative phase of elective orthopaedic patients View project

An Aerostat Tracking System Based on WebGIS Services Architecture View project

All content following this page was uploaded by Ping Yu on 22 September 2014.

The user has requested enhancement of the downloaded file.

APAMI 2012 Conference Proceedings

DEVELOPING AN ONLINE PATIENT APPOINTMENT SCHEDULING SYSTEM

BASED ON WEB SERVICES ARCHITECTURE

Xiaojun Zhang a1, Dr. Ping Yu a2, Dr. Jun Yan a2, Hongxiang Hu a3, and Dr. Niraj Goureia b
a
School of Information System & Technology, University Wollongong, Wollongong, Australia
b
Centre Health Complex, Shellarbour Health Care City, Australia
ABSTRACT information that is most important to them, design and
implement integrated clinical information system that
Currently, many healthcare providers in primary health care supports smooth information transfer between different
use computerized information systems to a certain extent. primary care practitioners [3].
However, the problem of heterogeneous information sources As a response to this paradigm, there is a trend for the
has impeded the integration of health care information development of integrated and better coordinated PHC
within primary health facilities. How to facilitate services across the full range of different care providers,
information sharing among the different healthcare such as General Practitioners (GPs), physicians, specialists,
providers has been recognized as a growing area of therapists, and even alternative medicine practitioners, to
significant importance due to its role in enhancing patient optimize patients’ medical services through a single service
centered, continuity of care. However, the design and entry point that minimizes the reliance on external resources
implementation of integrated health information system is [6, 7]. Archiving such integration requires the establishment
challenging due to the heterogeneity and autonomy of of a loosely coupled and broadly-based enterprise in which
different clinical specialties and differences in ownership of different health care providers collaborate in pursuit of a
clinical practice and resulting differences in information common set of objectives [6, 8]. Current health care
systems that they use. The emergence of the Web Services organizations, however, own large number heterogeneous
Technologies brings the opportunity to addressing the above information sources that impeded the information sharing
challenges by using new set of technological solutions. This and exchanging within primary health [9]. This is because
paper proposes an online patient appointment scheduling most of current existing health care systems consists of
system based on the Web Services architecture. The analysis isolated, stand-alone applications operated by different
and implementation results show that the Web Services Database Management Systems (DBMS) [9-11]. The
architecture provides an ideal design paradigm for the following scenarios illustrate the heterogeneous problem in
development of integrated health care information system in a regional medical centre:
the primary care setting • The main clinical system, which is mainly used by
Index Terms—Primary health care, Web services GPs, is installed on the Windows Server platform,
technology, SOAP, HTTP, Extensive Makeup Language serving for various tasks, including patient
(XML),
appointment scheduling, bulk billing, patient
1. INTRODUCTION medical information recording and updating, etc.
All operations are managed by Windows SQL
Over the last two decades, the primary health care (PHC) Server.
has become the most important healthcare service in many • The allied health practitioners use a different
developed countries. This is because it provides continuing system installed on the Linux platform for patient
and universally accessible health care services to the local
scheduling and medical recording. This
individuals and families in a community [1, 2]. In recent
years, the concept of “patient-centeredness” has become the application is managed by a Linux Open Source
norm in primary health care [3]. In comparison with disease- Database Server.
centered, technology-centered or physician-centered health • These two clinical information systems are
care practices, the patient-centered primary care practice operated separately by practitioners with different
requires care providers to consistently address patients’ workstations. These workstations are connected to
concerns and adequately share management options with the internal Intranet, creating a distributed
patients [4, 5]. David et al. illustrated main characteristics of computing environment. However, due to the
patient-centered primary care practice [3], including patients differences in system platform and DBMS, patient
can easily access primary care services and elicit
APAMI 2012 Conference Proceedings

information cannot be shared or exchanged across with a web-browser through Internet. The third-tier -
these two systems. enterprise information tier (EIS) is composed of a group of
From above description, it can be seen that the key adapters to connect with the existing CIS or any future CIS.
challenge to achieving integrated PHC services is to create The middle-tier connects the first tier with the third tier for
an infrastructure that can uniformly integrates medical data information exchange. The overall system architecture is
from heterogeneous information sources and deliver them to illustrated in Figure 1.
the relevant individual who need it at the every point of care The middle-tier uses a web server to connect to the
[12-15]. Internet and handles the HTTP requests exclusively for the
Addressing this challenge as a growing area of concern, static contents, such as static HTML files and images. It
extensive studies have been conducted [16-20]. Among responses user’s request with HTTP protocol, such as
these studies, the Web-Services technology is introduced sending back a HTML pages. In case the HTTP request is
into the health care information system development [21- related to patient appointment scheduling services, the web
23]. It has been used as a unified platform to supporting server will delegate the dynamic response to another server-
integration of disparate systems in computer industries [24]. side application located at application server to process the
This approach uses a commonly-agreed and general request. The results response from application server will be
technical mechanism for assembling software components converted into HTML format through web server and
in a modular way and invoking services exposed by an displayed in the standardized HTML Web Page.
information system [25-27]. It is built on a set of baseline
specifications, which include Simple Object Access
Protocol (SOAP), Web Services Description Language
(WSDL), and Universal Description, Discovery, and
Integration (UDDI) [28]. As a result, any system capable of
parsing text and communicating via a standard Internet
transport protocol, such as HTTP, SMTP or XML, can
communicate with a Web Service [28-30]. A centralized
Web service can enable seamless integration of various
clinical information systems in different settings and
provide universally accessible medical services to patients.
Easily making an appointment with preferred date and
time is a main characteristic of patient-centered primary care
practice [3]. To enable the establishment of patient-centered
primary health care, an integrated online patient
appointment scheduling approach based on Web-Services
architecture is proposed in this paper. The goal of this
research is automated patient appointment scheduling
process by integrating distributed clinical systems into a set
of consistent and convenient services accessible via a web
browser. The overall architecture of proposed approach is
presented in Section 2. A detailed description and analysis
of the implementation and adoption results are given in
Section 3 and 4, respectively. Finally, Section 5 concludes
this paper and outlines the future work.

2. THE OVERALL ARCHITECTURE OF ONLINE

APPOINTMENT SYSTEM
Figure 1. The architecture of proposed patient appointment scheduling
As there already were several clinical information systems system
such as Medical Director 3 (MD3) for general practitioners User login and registration requests are processed by the
(GPs) in the medical centre, a three-tier architecture was portal server which located in middle tier. The security
developed to enable communication and information mechanism in login process is enhanced through a MD5
exchange between the online appointment system and the hash generator. This encrypted login procedure ensures that
existing clinical information systems (CIS), or be scalable to only identified users can access the relevant medical
integrate with any CIS that will be introduced in the future. resources.
In the first-tier, patients can access appointment information
APAMI 2012 Conference Proceedings

The application server is a component that manages the 3. THE IMPLEMENTATION OF ONLINE
complete end-to-end appointment tracking and scheduling APPOINTMENT SYSTEM
services. The key functions of application server include: (1)
multiple-practitioner scheduling, (2) centralized and The online appointment system was developed by the first
consolidated patient appointment tracking, (3) available author and installed in a server machine in the CHC at the
appointment searching, (4) appointments rescheduling, and end of January 2011. There is a web link at the home page
(5) appointment confirmation and cancellation. of the medical centre Web site, clicking on it would allow a
A middle-tier database is used to cache the data retrieved person to enter the web-based online appointment system.
from EIS-tier database in order to minimize network traffic Information about the online appointment system was
flow and disk access. In addition, detailed information about disseminated to consumers through the following channels:
each scheduled appointment slot, such as patient login and (1) fliers to be left at the reception desk for anyone to take
contact information, is also stored into the middle-tier for fee; (2) posters placed at the prominent locations in the
database. medical centre; (3) advertisement at CHC web site. The
The message exchange server is designed to provide information disseminated includes the web link to the online
gateway services to facilitate the assembly, dispatch, receipt appointment system, the steps to follow to make an
and assimilation tasks. It is developed to meet all integration appointment using the online appointment system. Figure 2
requirements within heterogeneous clinical information shows the patient login web page.
systems. In such a way, additional clinical systems can be
subsequently integrated into the system through the use of
so-called “adaptors”. In addition, a set of common libraries
and infrastructure components are developed and applied by
message exchange server to make the whole architecture
extensible. The key functions of message exchange server
include: (1) dispatch and receive messages between external
and internal entities, (2) assemble and assimilate messages
that entering and existing core clinical applications, (3)
standardize integration procedures such as event logging,
exception handling and auditing, and (4) cache the
appropriate appointment information in order to improve
system performance.
The appointment adaptors in the third or EIS tier are
used to retrieve and transfer appointment information from
the heterogeneous clinical databases into a well-formed
XML document for transmission. These adaptors provide
unified interfacing between the clinical information systems
and message exchange server. The message exchange server Figure 2. Patient login web page
acts as a standardized interface between clinical information Once a patient has successfully logged in, the
systems and the middle tier. New adaptors can easily be appointment selection web page will be displayed as shown
developed to support other clinical systems, such as in Figure 3. The patient can select their preferred
pathology or preventive health care systems. With the appointment date, time and doctors. If the initial preference
utilization of adopters, the amount of development efforts cannot be met, an alternative choice will be presented
required to build extensive applications are minimized by automatically, including the available time, date and doctors
means of using standardized common libraries and in the medical centre. After patients make their final choice,
components developed to overcome the heterogeneous a confirmation web page will be displayed as shown in
problems. Figure 4.
The current existing clinical information systems (CIS)
in the EIS tier, including GP system and the allied health
system, are regarded as heterogeneous and autonomous
information sources that store the information about
patients, practitioners and appointment scheduling. These
systems are integrated with application server through
adapters and message exchange server.
APAMI 2012 Conference Proceedings

but steadily from 3.20% to 3.70%, then 4.40% at four, five

and six months after the online appointment system went
alive. The patient throughput in the medical centre per day
is around 300 people, among them 10, 11 or 13 people made
their appointments to see their GPs through online
appointment system in the 4, 5, or 6 months after the online
appointment system was implemented, respectively.

Adoption Rate

Adoption Rate of Appointment

5.00% 4.40%
3.78%
4.00%
3.20%

Made Online
3.00%
Figure 3. The page of Selecting Appointment 2.00%

1.00%

0.00%
April May June
Month of survey, 2011

Figure 5 Adoption rate of online appointment

The diffusion of innovation theory indicates that the
adoption process can be divided into five segments:
innovators, early adopters, early majorities, late majorities
and laggards [31]. Rogers suggests that innovators
constituted around 3% of the total population [31]. As it is
shown in the Figure 6, the overall adoption rate of the online
appointment system had slowly increased from 3.2% to
4.4% over the three months survey period. It appears that
only the innovators in the patient population had adopted the
Figure 4. Confirmation web page IT innovation – the online appointment system. The
The confirmation web page provides an opportunity innovators were belonged to the 15% of the patient
for patients to reconsider their choices before the population who used the Internet to access the web site of
information is finally stored into the database. It displays the medical center. This may indicate that Internet-based
start and end time of the appointment, patient’s name and healthcare delivery is still far from the reach of the general
doctor’s name. Patients can reselect a new appointment slot public in the regional Australia, where the study site
or cancel the current selection. Once the patient clicks belongs. However, 61% of the patient population expressed
“Confirm” button, the appointment confirmation service is their intention to use web-based self-service applications.
involved and the appointment information will permanently This information is supportive of Australian government
be stored into the clinical database. Then the system will initiative of introducing Personal Controlled Electronic
generate a confirmation e-mail letter and send it to the Health Record System (PCEHR) in Australia.
patient’s e-mail address.
5. CONCLUSION AND FUTURE WORK
4. IMPLEMENTATION RESULTS
This paper proposed an online patient appointment
Figure 5 shows the adoption rate of online appointment after scheduling system built on the Web Services architecture in
three months of implementation. The adoption rate of the a heterogeneous healthcare environment. It shows that the
online appointment system was gathered from the log record Web Services architecture provides an appropriate paradigm
of the online appointment system. It was increased slowly for the development of an integrated health information
APAMI 2012 Conference Proceedings

system which enables the communication among [7] William T. O'Donohue, Michella R. Byrd, Nicholas A.
heterogeneous, autonomous and distributed healthcare Cumings, and Deborah A. Henderson, Behavioral Integrative
information systems. The prototype system demonstrates the Care Treatments That Work in the Primary Care Setting New
feasibility of the architecture. The future work will be York: Routledge, USA, 2005.
focused on integrating the new clinical applications into the [8] M. B. Kenkel, P. H. Deleon, E. O. Mantell, and A. E. Steep,
system. "Divided No More: Psychology's Role in Integrated Health
Care," Canadian Psychology, vol. 4, pp. 189-202, 2005.
This case study serves as a preliminary study for the
[9] Magdi N. Kamel and Moshe Zviran, "Heterogeneous
future analysis of consumer’s acceptance and usage of e-
Databases Integration in a Hospital Information Systems
Health applications, such as PCEHR in primary health care Environment: A bottom-Up Approach," AMIA, pp. 363-367,
in regional Australia. Future statistical analysis of 1992.
qualitative and quantitative results will be undertaken to [10] F. Ceri and G. Pelagatti, Distributed Database: Principles
improve our understanding of the patient’s behavior in and Systems. New York: McGraw-Hill, 1984.
adopting e-health application and the factors that impact on [11] D. K. Hsiao and M. Kamel, "Heterogeneous Database:
the adoption behavior. Our preliminary findings are highly Proliferations, Issues, and Solutions," IEEE Transactions on
valuable for the decision makers charged with the Knowledge and Data Engineering, vol. 1, pp. 45-62, 1989.
responsibility of implementing PCEHR to consider in [12] C. E. Chronaki, D. G. Katehakis, X. C. Zabulis, M. Tsiknakis,
designing their strategies and plans for the introduction of and S. C. Orphanoudakis, "WebOnCOLL: medical
the PCEHR system in regional Australia. collaboration in regional healthcare networks," Information
Technology in Biomedicine, IEEE Transactions on, vol. 1, pp.
9. ACKNOWLEDGES 257-269, 1997.
[13] M. Tsiknakis, D. G. Katehakis, and S. C. Orphanoudakis,
This research has been supported by Centre Health Complex "Information infrastructure for an integrated healthcare
(CHC) under the grant from both CHC and University of services network," in Information Technology Applications in
Biomedicine, 2000. Proceedings. 2000 IEEE EMBS
Wollongong. The authors would like to thank the works of
International Conference on, 2000, pp. 278-283.
Dr. M.K. Rashid, Dr Niraj Goureia and Violeta
[14] C. E. Chronaki, V. Kontoyiannis, M. Mytaras, N. Aggourakis,
Kuzmanovska for giving us both inspiration and insight to
S. Kostomanolakis, T. Roumeliotaki, G. Kavlentakis, F.
achieve our technical implementation of this work. Chiarugi, and M. Tsiknakis, "Evaluation of Shared EHR
Services in Primary Healthcare Centers and their Rural
11. REFERENCES Community Offices: the Twister Story," in Engineering in
Medicine and Biology Society, 2007. EMBS 2007. 29th Annual
[1] R. Anzböck and S. Dustdar, "Modeling and implementing International Conference of the IEEE, 2007, pp. 6421-6424.
medical Web services," Data & Knowledge Engineering, vol. [15] P. A. Bath, "Health informatics: current issues and
55, pp. 203-236, 2005. challenges," J. Inf. Sci., vol. 34, pp. 501-518, 2008.
[2] L. Fleisher, J. Buzaglo, M. Collins, J. Millard, S. M. Miller, B. [16] Pradeep Ray, Daraesh P. Mistry, and Graham Low, "Hospital
L. Egleston, N. Solarino, J. Trinastic, D. J. Cegala, A. B. Information Systems based on CORBA and HL7," HIC2000,
Benson Iii, K. A. Schulman, K. P. Weinfurt, D. Sulmasy, M. Integrating Information for Health Care pp. 1-9, 2000.
A. Diefenbach, and N. J. Meropol, "Using health [17] D. Krechel, M. Hartbauer, and K. Maximini, "LENUS - The
communication best practices to develop a web-based Hospital Content Management System," in Computer-Based
provider-patient communication aid: The CONNECT(TM) Medical Systems, 2006. CBMS 2006. 19th IEEE International
study," Patient Education and Counseling, vol. 71, pp. 378- Symposium on, 2006, pp. 9-14.
387, 2008.
[18] W. Weiping, W. Mingming, and Z. Shijun, "Healthcare
[3] Karen Davis, Stephen C. Schoenbaum, and Anne-Marie J. information system integration: a service oriented approach,"
Audet, "A 2020 VISION OF PATIENT-CENTERED in Services Systems and Services Management, 2005.
PRIMARY CARE," Journal of General Internal Medicine, Proceedings of ICSSSM '05. 2005 International Conference
vol. 20, pp. 953-957, 2005. on, 2005, pp. 1475-1480 Vol. 2.
[4] Campion P, Foulkes J, Neighbour R, and T. P, "Patient [19] Khalil Khoumbati and Marinos Themistocleous, "Integrating
centeredness in the MRCGP video examination: analsis of the IT Infrasturctures in Healthcare Organisations: a
large cohort," BMJ, vol. 325, pp. 691-692, 2002. Propositioin of Influential Factors," The Electronic Journal of
[5] Marvel MK, Epstein RM, Flowers K, and B. HB, "Soliciting e-Government vol. 4, pp. 27-36, 2006.
the patient's agenda: have we improved?," JAMA, vol. 281, pp. [20] Gail D. Armitage, Esther Suter, Nelly D. Oelke, and Carol E.
283-287, 1999. Adair, "Health Systems integration: state of the evidence,"
[6] C. E. Hine, H. B. Howell, and K. A. Yonkers, "Integration of International Journal of Integrated Care, vol. 9, pp. 1-11,
Medical and Psychological Treatment within the Primary 2009.
Health Care Setting," Social Work in Health Care, vol. 47, pp. [21] M. Barhamgi, D. Benslimane, and P.-A. Champin, "A
122 - 134, 2008. Framework for Data and Web Services Semantic Mediation in
 APAMI 2012 Conference Proceedings

Peer-to-Peer Based Medical Information Systems," presented

at the Proceedings of the 19th IEEE Symposium on Computer-
Based Medical Systems, 2006.
[22] M. Mrissa, D. Benslimane, C. Ghedira, and Z. Maamar, "A
mediation framework for Web services in a distributed
healthcare information system," in Medical Information
Systems: The Digital Hospital, 2004. IDEAS '04-DH.
Proceedings. IDEAS Workshop on, 2004, pp. 15-22.
[23] M. P. Papazoglou and W.-J. Heuvel, "Service oriented
architectures: approaches, technologies and research issues,"
The VLDB Journal, vol. 16, pp. 389-415, 2007.
[24] Scott Mitchell. (2008) An extensive examination of web
services: part 1.
[25] Susan M. Salkowitz, Noam H. Arzt, and R. Gubernick,
"Immunization information systems and healthcare systems
interoperability," APHA 136th Annual Meeting and Exposition,
2008.
[26] J. Mykkänen, A. Riekkinen, M. Sormunen, H. Karhunen, and
P. Laitinen, "Designing web services in health information
systems: From process to application level," International
Journal of Medical Informatics, vol. 76, pp. 89-95, 2007/3//.
[27] Cerami. Ethan, Web Services Essentials: O'Reilly, 2002.
[28] M. Turner, F. Zhu, I. Kotsiopoulos, M. Russell, D. Budgen, K.
Bennett, P. Brereton, J. Keane, P. Layzell, and M. Rigby,
"Using Web Service Technologies to Create an Information
Broker: An Experience Report," presented at the Proceedings
of the 26th International Conference on Software Engineering,
2004.
[29] M. Hori and M. Ohashi, "Applying XML Web Services into
Health Care Management," presented at the Proceedings of the
Proceedings of the 38th Annual Hawaii International
Conference on System Sciences (HICSS'05) - Track 6 -
Volume 06, 2005.
[30] N. Pitts and Kirk. Chery, The XML Black Book: Coriolis
Technology press, 2000.
[31] E. M. Rogers and A. Singhal, "Diffusion of Innovations," in
An Integrated Approach to Communication Theory and
Research, M. Salwen and D. Stacks, Eds., ed Mahwah:
NJ:LEA, 1996, pp. 409-419.

View publication stats