Telephone and Internet-based medical appointments ('CMTI')

Author : Luis Angel Rodríguez-Alemán
Date added : 2003-09-26

Brief Project Background

The project started back in May 2001 when the Director General of the Social Security and Services for the State Workers Institute (ISSSTE, by its spanish acronym) decided to tackle the problem of the excessive time -the real figure at the time was a little bit over 4 hours waiting time- that the users of the medical services of ISSSTE used to wait in order to get medical attention at the 168 first-level family healthcare clinics nationwide. He then assigned the underdirection of information technology (the CIO’s organization) to solve the problem. The CIO in turn assigned the problem to the Automation of Medical Services Service Chief. The solution we found was to create a system of medical appointments that would translate into a new more comfortable “counter” for ISSSTE users: a call center and a web-enable system that would be in place for the people to make appointments with anticipation from any telephone or computer connected to the internet. This system would handle the schedules of all the family healthcare clinics in the country and would make more efficient the operation of the clinics by virtue of helping them to organize their workloads with anticipation and thus enabling them to provide a better service (at least in terms of smaller waiting times and better punctuality) to the people. It is important to mention that this project was risen to the level of “presidential target”, implying that reports of progress must be submitted monthly to the office of the President of Mexico.

The project started back in May 2001 when the Director General of the Social Security and Services for the State Workers Institute (ISSSTE, by its Spanish acronym) decided to tackle the problem of the excessive time -the official figure at the time was a little bit over 4 hours waiting time- that the 10.2 million users of the medical services of ISSSTE used to wait in order to get medical attention at the 168 first-level family healthcare centers (we will refer to them as the “clinics” from now on) nationwide .

Let us start by describing how the process of obtaining a medical appointment and/or getting medical attention used to be at the time. To start with, there were no medical appointments as such in the whole of ISSSTE’s healthcare network. Some clinics had established a “local appointment” only for their assigned users, which is the segment of population that is assigned to a certain clinic. They took one of the scarce clinic phone lines and assigned it for the incoming calls requesting appointments, which usually were made only with 24-hour advance notice.

The solution that we found was to find a way in which every and each ISSSTE user was able to make an appointment for medical attention by phone or over the internet (creating, as a matter of fact, the concepts of “appointment” and “punctuality”). This appointment would represent a commitment to provide the attention with a certain doctor, in a certain date and time.

In order to achieve this, we thought the best solution would be to set up a call centre and to develop an internet based system called “ISSSTE’s medical appointment by phone or internet (“Cita Médica Telefónica y por Internet” or CMTI system)” that would be used by the call centre operators, clinics’ employees and end-users.

The whole process works as follows:

a) A purported ISSSTE user makes a phone call to the toll-free number of a call centre. The operator picks up the phone and asks for the persons “fiscal number” (which works as a unique identifier or key) and types it in the CMTI which in turn automatically connects to the national database of registered valid users (SIPE) to see whether the number belongs to a valid ISSSTE user . If it does, then the operator offers the available time slots for the date that the user wants and once the negotiation concludes and the appointment is properly registered in the system (and some other data, like a telephone number -if available- to potentially contact the user in the future) the operator gives a confirmation number to the user.

b) Likewise, users can also make appointments on-line accessing the CMTI through the internet.

c) Or, users can make appointments in the clinic itself (i.e. let’s say that a physician asks a patient to return in one week for a second session) by asking a clinic employee at the “CMTI appointments” counter to register an appointment in the CMTI using the clinic’s computer via internet (only in the clinic will the system register a same-day appointment).

Once a user with a pre-arranged appointment arrives to the clinic all they must do is show up at the special “CMTI appointments” counter 15 minutes early to announce his attendance to the appointment by mentioning his/her confirmation number and showing any identification, then going on to the corresponding cubicle. The clerk at the counter then proceeds to mark on the system the person’s attendance, in order to create a historical database that can yield information about frequency of attendance, percentage of no-shows, etc.

The key for this system to work properly, in order to make the appropriate appointments for the users is the two-way communication between clinic’s and call centre (including the central schedule database), as can be seen in the diagram below. On the one hand, each clinic must permanently inform to the system its installed capacity (number of cubicles, types of service, work schedules of each of them, etc.) as well as the contingencies (a cubicle that will close in certain dates and time due to several reasons), in this way the system will only offer to the users the slots that are really available and guarantee the attention at the committed time. On the other, the system (which resides in a server in the call centre facilities) “reports” at any time -printout or screen- (on-line) to each clinic the appointments that have been made on its behalf. For this reason, clinics must comply with a series of requirements (in terms of their own internal organizations and the way they assign their population to their physician’s cubicles) to be able to adopt the new system. Therefore, we started the project by conducting a diagnosis of the 168 target clinics and telling them the things they had to fix before they could adopt the system (and we still do that every day in order to identify new clinics as they get ready for implementation).

The system has also included it’s own mechanism to raise complaints against the way the new service is working. This complaints can be entered through the call centre, personally through the internet, or through the system’s “terminal” at the clinic’s counter.

Likewise, users can use the system to request an interview with the clinic’s director, in order to discuss quality-of-service issues, etc.

Regarding the technology, it is quite simple. The back office is (1) a SQL Server 2000 database, which is used by a web-enable system using ASP pages developed with Interdev v. 7, and (2) a call centre that uses computer-telephony integration and a series of devices to optimise the management of the phone calls. The system sends queries to the SIPE affiliation database through a private link connecting the SIPE server and the CMTI server.

Results

The system is currently working in 116 clinics, with a total of 16 states (including Mexico City) totally covered (with all their clinics working with the system) and 12 states partially covered (some clinics use the system and some still don’t). We are expecting to end 2003 with a total of 144 clinics in the system, and to cover the whole 168 family healthcare clinics in the first half of 2004.

The project’s results are multi-fold:

· It has become a new way to shorten the distance between ISSSTE and its users, by virtue of the opening of a new “counter” that never existed before and that is much closer to the patients. It is important to note that the ISSSTE healthcare network provides services to people living all throughout the country, sometimes in very distant rural posts (wherever there are federal government employees) where the nearest ISSSTE facility is several hours away by any transportation mean.

· Web access to this system has been included in the official portal of the federal Mexican government, www.tramitanet.gob.mx

· At the macro level, undoubtedly the main achievement of the program is the reduction in the productivity loss (for the government and thus for the country). That is, we must account for the amount of hours that the federal employees (ISSSTE users) used to “waste” when they had to attend the medical services, and therefore they had to stop working.

· The new service has provided a unique opportunity for the Institute to give an incentive to its affiliates to come update their registration information as well as that of their families.


· In order to understand the next positive impact of this program it is necessary to explain that ISSSTE has assigned each affiliate to one first-level-attention medical unit on a geographical basis.

· The next result is extremely important because as simple as it looks, it had not been achieved ever before. It turns out that physicians hired by ISSSTE to work in the first-level-attention medical units, work in 2 shifts: from 8:00 a.m. to 2:00 p.m. or from 2:00 p.m. to 20:00 p.m. Now with the new system, as people come in with a time previously committed, they demand the physicians to be there and to be punctual, and this works as a “social comptrollership” for the physicians who are forced by their very patients to stay at the clinic during their full shift (do not arrive late, do not leave early, do not go out for breakfast at the middle of the morning) and to organize their work in order to see each patient with punctuality.

· In addition, the clinic’s have re-organized many activities that are touched upon by the new appointment system. This is because as small a process as the appointment-making seems to be, in the context of the series of processes that take place in a clinic, it turned out to be -very much to our surprise- one that is deeply entangled with many others in the clinics.

Regarding the way the new service has been adopted by ISSSTE users which is, by far, the most important measurement of success, we can mention the following (information as of august 2003):

· Average incoming calls attended daily (mon-fri): 9387.
· 90.4% of incoming calls are answered in less than 14 seconds.
· 77.3% of incoming calls attended end up in an appointment.
· Number of appointments arranged via the CMTI system up to last august 31: 1,816,346.
· Number of appointments arranged via the CMTI system in 2003 (up to august 31): 1,161,896 (which implies that the acceptance and use of the system is still increasingly growing).


In year 2002, this project was awarded the INNOVA prize, awarded by the Office of the President of Mexico to the most innovative projects in the Mexican federal government with the largest positive impact on the population.

Finally, CMTI has demonstrated it’s potential to be implemented in other clinical services -such as laboratories, X-rays, etc.- as well as other levels of attention -second and third-levels-. We have actually developed (with the approval of the central medical authorities) already all the procedures to implement the medical appointment by telephone and internet for the second-level or clinics of specialities, as well as conducted the analysis for the software. Unfortunately we have not gotten the authorisation to go on and run a pilot, but we are sure that the impact among the users will be even greater than that of the current CMTI in family healthcare clinics. This is due to the fact that currently patients who want to see an specialist must go twice to the clinic: they go any day to ask for an appointment which is registered in the specialist schedule (yet all they get is a date, but not a certain time committed), afterwards on the date of the appointment they show up and wait for their turn. With the system they will be able to get an appointment by internet or telephone (eliminating altogether the first trip) and then show up on the date and time of their appointment to receive the attention punctually.

Lessons

1. It has become crystal clear that big projects in big organizations should preferably start running a prototype or pilot project with clearly defined boundaries and indicators. These pilots help detect surprises (like the physicians disrespect for their work schedules, or the clinics’ informal arrangements, in our case) that escape to the best planning processes, and must be as widely inclusive as possible.
2. It became also very clear that better results can be attained when certain aspects are left to the people. In our case, we left things that are very local in nature to the clinics’ directors. In giving this leeway to the local leaders, we gained a more serious commitment to the project, as they felt it was their project, -they complained that they were very seldom taken into account in the design of the projects that they would later carry out.
3. In order to overcome hurdles more easily, and to gain support it is important to give visibility to the projects, but never create over-expectations. In fact, many e-government handbooks recommend to start e-government with something very visible, with direct impact on the people, in order to gain political and managerial support and to earn support for future projects.
4. As much as we wanted the system to gain rapid acceptance from the users, we did recognize the necessity to keep the old, traditional window up and running. This decision obeyed to a series of factors including telephone availability, and above all customs: people were accustomed to the old method, regardless of how inconvenient it was.
5. It has been very important for the success of the project to provide feedback to all the “stakeholders”, like the monthly report that we send to the state delegations showing the performance of each clinic. We also conduct in-situ evaluations on a random basis, and share the results with the clinics’ directors, state delegates, etc. Equally, it was very important to provide “incentives” for the adoption of the new system, i.e. we convinced the medical central authorities of ISSSTE to “tie” the “clinic’s quality certification” process to the adoption of the system, as one of the many pre-requisites to be certified.
6. The success of this project was mainly due to the huge planning that was conducted.
7. We embraced a process of “learning by doing” (I already mentioned we gave a lot of leeway to the directors to certain “local” aspects) and we, as the area that was in touch with all the clinics, adopted a policy of “best practice broadcasting” trough which we actively tried to disseminate new good practices that arose in any clinic and that proved efficient to the rest of the clinics.
8. As in every new system, the human part of it is by far the most difficult, much more than the technical. Therefore, implementation was key. A great deal of planning was done before and during the implementation he pace of implementation was a main success factor: it was slow. A team of 2 persons remained for one full week in each clinic to implement the system successfully and to assure that it would keep working once we left that clinic.
9. Internally in the Institute, the fact of establishing clear annual goals, which are in turn clearly related to a comprehensive and detailed annual budget, has helped to assure the availability of all the financial and material resources necessary to keep the project up and running as well as in continuous expansion. As the area in charge of the project, we committed ourselves to achieve certain goals if and only if we were provided with the resources we stated at the beginning of the fiscal year, nothing less but nothing more. We budgeted everything ranging from photocopies (including paper and toner) to per diem expenses to the operation costs of the call centre, to mention a few items.
10. When we started the project the expectations about the clinic’s employees were very bad, as everybody regards ISSSTE’s unionised workers in a very negative way. However, as we started the implementation of the system we soon realized that many of that people were very enthusiastic and seemed to be waiting for an opportunity to work in a well-organized project and that would, by itself, incentive them to work harder. They complained that many projects had started but most of them were short-lived because many aspects were never planned for and went into failure, but as they started to realize that commitment to excellence was a differentiating element of this new project, we gained their trust, and that trust became a valuable asset.
11. Although the project was not devised to improve the transparency, it has had 2 impacts on that line, demonstrating that technical solutions are incontestable and often better than arguments. First, the case of doctors’ work schedules that we already mentioned as an ever-lost battle against the union. Whenever a new clinic director came in to the post and tried to put a solution to this problem s/he would end up deposed, it was like a third rail never to be touched. Now, with the people accessing the doctor’s schedules directly -through the system- the directors cannot be accused of putting pressure on doctors to comply with their full shifts. Second, some people at the clinics counters used to “sell” the turns in the queue to see a doctor. This practice gets abolished as more and more time slots are filled with the people that makes appointments in advance.

Development Impacts

We now want to quote the Centre for Democracy and Technology and InfoDev E-government Handbook, when they state that, “E-government is not just a cost cutting or efficiency initiative, but rather is directed at bettering the lives of ordinary people.” And that, bettering the lives of ordinary people, is precisely the goal of the CMTI. And bettering the lives of ordinary people, of millions of them clearly entails, I believe, a potential for development, as any other investment in the well-being of people does (including the more traditional investments in human capital, such as education and health: this system is indeed an additional investment in the quality of the public health services).

Let us think in terms of the context of the lives of millions of impoverished employees from the low ranks of governments. Their only option for medical services is ISSSTE, they cannot afford attending the private medicine. Yet they deserve to receive good-quality attention. It is unfair to make them wait in endless queues just because they have to tolerate it quietly, or remain without any medical assistance whatsoever. It is a matter of equity, to provide them with services of similar quality to those that can receive any other citizen. Why do the people that can pay for private medicine have the right to choose at what time they want to attend the hospitals and be received relatively punctually whereas people who cannot pay have to wait with total uncertainty about the time they will be seen? Is it correct to make sick people, feeling unwell, to wait hours in crowded waiting rooms to be seen by a doctor?

I ask the reader to momentarily leave his/her own situation and think in terms of a single mother who works at the federal government. Every time she or one of her children gets sick, she must take all the hassle that we’ve described... and miss, many times, a full working day.

Let us now think of the rural people. Often times they have to travel long distances (in not very convenient roads or without comfortable transportation means) to reach the nearest clinic. If we add to that the uncertainty about the time when they will get to see the doctor, and the very long average waiting time, we can understand that they will probably set a whole day aside only to receive 15 minutes (the standard duration of the interview with the physician) of medical attention. One could very well take a guess that they probably postpone the visit to the clinic until the moment when they really feel sick, which is contrary to the nature of first-level healthcare.

Clearly, to the extent that this new service is contributing to correct those problems, it is bolstering the potential for development of those people, and their communities, all over the country. To the extent that those people can save many hours, as compared to before the implementation of the system, they can use that time for any other things, ranging from work to leisure, but in any case something that is on their curve of preferences, as opposed as something they must do because there is no option.

We now turn to the issue of the reduction in the lost productivity for the government. ISSSTE gives around 9 million medical interviews in the first-level of attention every year. If we consider that each of them could on average save some 3.5 hours of the reduced waiting time (let alone the fact that they skip the “affiliation” queue altogether), that means that 31.5 millions manpower/hours would be saved in the country (and its associated cost). Therefore, the system generates savings for ISSSTE, but above all, for the federal government (as employer) and the country as a whole (we are talking of about one tenth of Mexico’s population).

On the other hand, this services is, as a side effect, helping a number of people jump the digital divide. That is because many of the people who are working in the clinic’s counters (especially in little towns) had never before had access to the internet nor e-mail. Now as part of the implementation activities around the system, we provide some basic training in using the internet and an e-mail system.


To wrap this up, I will say that, given the vastly positive response of the users towards the system, I am confident that the users themselves would never allow this service to disappear. Actually, several clinics that at the beginning were reluctant to do their homework in order to adopt the system, were pressed by the community of users to hurry up and adopt it. Internally, the personnel working at the clinics’ counters, as well as the directors of the clinics, have also expressed that they would never go back to the old manual system (with first-in-first-out turns instead of appointments). Therefore, the system is posed to continue growing until completion of the national first-level clinics network, and hopefully to move on to the other 2 levels of attention as well as other clinical services at ISSSTE.

Project Information

Organisation : Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE (Social Security and Services for the State W
URL : www.issste.gob.mx/issstenet
Total budget in US$ : $3,000,000
Country of activity: Mexico [MX]

Are there any partners involved : Call centre & Application Service Provider
What is partners role?: ISP

Contact Information

Luis Angel Rodríguez-Alemán
larodriguez@issste.gob.mx ,lar4@georgetown.edu,a.rodriguez-aleman-alumni@lse.ac.uk
Río Rhin 3 piso 9 Col. Cuauhtémoc , 06500, Mexico City, (+52-55) 5140-1105 and 5601-

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