Assessment of outpatient department online booking system at Yangon General Hospital
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Key findings
• More than 90% of patients expressed satisfaction with the online booking system.
• Major challenges were the lack of technical skills of users and poor connections.
What is known and what is new?
• An online booking system offers easier and more efficient patient management.
• The majority of patients prefer the online booking system to the traditional walk-in system.
• Major challenges in implementing online booking system that need to be promoted.
What is the implication, and what should change now?
• It is recommended to inform the public about how to use the online booking system through mass media.
• The online booking system should be continued and implemented in other public hospitals, especially in high-burden tertiary hospitals in Myanmar.
Introduction
Public hospitals play a critical role in providing healthcare services to the general population, serving as the backbone of many healthcare systems worldwide. In Myanmar, hospitals under the Department of Medical Services are responsible for providing curative healthcare services to ensure the provision of efficient and quality healthcare services (1). Currently, a total of 1,177 public hospitals are providing medical services, with Yangon General Hospital (YGH) being the largest public hospital in Myanmar. YGH is a 2,000-bedded hospital that operates medical wards, surgical wards, orthopedic and trauma wards, and specialist departments for inpatient care, along with 18 outpatient departments (OPDs). Patients in need of advanced care rely on both inpatient and outpatient services at YGH.
In Myanmar, nearly all public hospitals, including central hospitals, utilise conventional methods for scheduling outpatient appointments, such as walk-ins, follow-ups, and referrals from health centers, and healthcare professionals. There is no appointment system in place. Telephone booking has never been implemented in public hospitals due to insufficient human resources and management challenges associated with the complex scheduling of various departments. As a result, patients commonly face prolonged waits to secure a token number for an outpatient appointment. During the COVID-19 pandemic, finding more efficient ways to schedule appointments became critical in response to increasing patient demands for social distancing, avoiding overcrowding and minimizing disease transmission.
With the development of internet access and an increase in mobile users, telecommunications and online booking systems have become new trends. YGH launched the OPD’s online booking system in February 2022 to enhance accessibility and efficiency of patient management. This online booking software tool (Caremebot) enables patients to easily book or request appointments with just a few simple clicks from any internet-connected device. This online booking system aims to improve the quality of healthcare service by empowering patients to view and book medical appointments for themselves. Patients can securely and conveniently book and reserve outpatient services via the application from anywhere they are, at any time, without the need for a physical location or specific business hours. It can help reduce waiting times and promote patient satisfaction (2). However, the online booking system for OPD in our country is relatively new, so the effectiveness and feasibility of this system are not clearly known. This study aims to explore patients’ experiences and satisfaction with the online booking system of the OPD at YGH. The result of the study will contribute to the improvement of the existing online booking system at YGH by exploring its strengths and limitations, hence promoting its adoption in other hospitals.
Methods
A cross-sectional descriptive study with both quantitative and qualitative approaches was conducted at 15 OPDs of YGH from September 2022 to February 2023. For the quantitative study, a review of hospital records was undertaken, and a total of 179 patients who attended the OPD of YGH were recruited through simple random sampling and interviewed face-to-face using a structured questionnaire. The patients who utilized online booking for each week were listed and seven patients were randomly selected using a random number generator. The data was collected for 25 consecutive weeks.
For qualitative data, in-depth interviews (IDIs) were done with four randomly selected patients, and key informant interviews (KIIs) were performed with four individuals responsible for the online booking system, including doctors, nurses, and receptionist. The qualitative interview was conducted by independent researchers in a private room following the hospital appointment, using the interview guidelines.
Statistical analysis
Data were systematically collected and checked for completeness, errors, and inconsistencies. Data analysis was performed using SPSS version 16 software. Categorical variables were described in frequency and numerical variables by summary statistics. The satisfaction score was calculated by using the 5-point Likert scale as follows: ‘5’ for strongly satisfied, ‘4’ for satisfied, ‘3’ for neutral, ‘2’ for dissatisfied, and ‘1’ for strongly dissatisfied. The relative satisfaction score was calculated using the following formula (3). RSI = (5n5 + 4n4 + 3n3 + 2n2 +1n1)/5N.
For the qualitative study, the field notes and audio recordings from the IDIs and KIIs were meticulously checked against the interview guidelines after each session. These field notes and recordings were transcribed into full transcripts. Subsequently, thematic analysis was conducted and verified by three researchers using topics outlined in the interview guidelines.
Ethical considerations
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of the Department of Medical Research (Ethics/DMR/2023/002) and informed consent was obtained from all individual participants.
Results
During the study period (from September 2022 to February 2023), a total of 34,047 patients attended the 15 OPDs of YGH. Among them, 11,965 patients (35.1%) were appointed by online booking system. A total of 179 OPD patients who attended the 15 OPDs of YGH were involved in this descriptive study.
Demographic characteristics of outpatients
The mean age of patients is 47.9±17.4 years, in the range of 11 to 83 years. More than half of the patients were female and most (>80%) were Buddhist. More than half were married and dependent. About two-thirds of the patients had middle school education or lower, and nearly 70% resided in urban areas (Table 1).
Table 1
| Characteristics | No. of outpatients | Percentage, % |
|---|---|---|
| Sex | ||
| Male | 68 | 38.0 |
| Female | 111 | 62.0 |
| Religion | ||
| Buddhism | 148 | 82.7 |
| Christian | 11 | 6.1 |
| Islam | 16 | 8.9 |
| Hindu | 3 | 1.7 |
| Others | 1 | 0.6 |
| Marital status | ||
| Single | 45 | 25.1 |
| Married | 109 | 60.9 |
| Divorce | 9 | 5.0 |
| Others | 16 | 8.9 |
| Education status | ||
| Illiterate | 2 | 1.1 |
| Can read & write | 18 | 10.1 |
| Primary | 34 | 19.0 |
| Middle | 70 | 39.1 |
| High | 22 | 12.3 |
| University | 10 | 5.6 |
| Graduate | 23 | 12.8 |
| Occupation | ||
| Dependent | 97 | 54.2 |
| Retired | 8 | 4.5 |
| Servant | 22 | 12.3 |
| Own business | 27 | 15.1 |
| Others | 25 | 14.0 |
| Residence | ||
| Rural | 60 | 33.5 |
| Urban | 119 | 66.5 |
Knowledge and satisfaction with online booking system
Approximately 65% of patients reported that they received information about the online booking system from health care personnel, followed by family and friends (17%) (Table 2). Only about one-third of patients had made online booking by themselves whereas the majority (62%) by friends or family (Table 3).
Table 2
| Source of information | Frequency | Percentage, % |
|---|---|---|
| Health professional | 116 | 64.8 |
| Internet/social media | 17 | 9.5 |
| family/friends | 30 | 16.8 |
| Others | 16 | 8.9 |
Table 3
| Online booker | Frequency | Percentage, % |
|---|---|---|
| Family/friends | 111 | 62.0 |
| Self | 52 | 29.1 |
| Health professional | 15 | 8.4 |
| Others | 1 | 0.6 |
Nearly 20% of patients had no previous history of attending the OPD of YGH. Among previous users, more than three-fourths (80%) of patients stated online booking system is more convenient compared to the traditional walk-in system. Over 90% of the patients were satisfied with the online booking system and indicated that they would choose it for their next visit. Although the overall satisfaction with the online booking system is high, the relative satisfaction index (RSI) of the user-friendliness (RSI =0.77) is low compared to that of duration of online booking process (RSI =0.83) (Table 4).
Table 4
| Statement | Strongly dis-satisfied, n (%) | Dis-satisfied, n (%) | Neutral, n (%) | Satisfied, n (%) | Strongly satisfied, n (%) | RSI |
|---|---|---|---|---|---|---|
| Satisfaction with online booking system | ||||||
| The duration for online booking process is reasonable | 0 (0.0) | 32 (17.9) | 5 (2.8) | 98 (54.7) | 44 (24.6) | 0.83 |
| Online booking process is user-friendly | 0 (0.0) | 4 (2.2) | 7 (3.9) | 127 (70.9) | 41 (22.9) | 0.77 |
| Satisfaction with OPD services | ||||||
| Satisfy with the waiting time | 1 (0.6) | 3 (1.7) | 7 (3.9) | 138 (77.1) | 30 (16.8) | 0.82 |
| The waiting area is comfortable and clean | 0 (0.0) | 0 (0.0) | 2 (1.1) | 121 (67.6) | 56 (31.3) | 0.86 |
| Other staff's communication is good | 0 (0.0) | 1 (0.6) | 2 (1.1) | 117 (65.4) | 59 (33.0) | 0.86 |
| The waiting space is adequate | 0 (0.0) | 0 (0.0) | 2 (1.1) | 114 (63.7) | 63 (35.2) | 0.87 |
| Doctors’ communication is good | 1 (0.6) | 0 (0.0) | 1 (0.6) | 113 (63.1) | 64 (35.8) | 0.87 |
| Nurses’ communication is good | 0 (0.0) | 0 (0.0) | 3 (1.7) | 113 (63.1) | 63 (35.2) | 0.87 |
OPD, outpatient department; RSI, relative satisfaction index.
Satisfaction with OPD services
For the current appointment, the waiting time for more than half of the patients (50.8%) was 30 minutes to 1 hour, with 25.1% indicating within 30 minutes and only 22.1% lasting approximately 1–2 hours. Almost all patients (177, 98.9%) expressed satisfaction with the overall services of the OPD. The level of satisfaction was assessed using the RSI, revealing that waiting time received the lowest satisfaction rating from patients (RSI =0.82), followed by the cleanliness of the waiting area (RSI =0.86), and communication with other staff (RSI =0.86). The highest satisfaction was found in adequacy of waiting area, communication of doctors and nurses, all with an RSI of 0.87 (Table 4).
Qualitative findings
KIIs and IDIs were conducted to explore the experiences, strengths, and weaknesses of the online booking system from the perspectives of healthcare providers and patients. KIIs were conducted with a specialist, a nurse, a receptionist, and a medical superintendent who are primarily responsible for online booking. The age of respondents ranged from 26 to 54 years, with total work experience between 5 and 23 years.
IDIs were conducted with two male and two female patients, including individuals with varying perceptions on a visual analogue scale (two with good perception and two with moderate perception). Respondents reported diverse educational levels, including one with primary school education, one with middle school education, one with high school education, and one graduate degree. Three-fourths of the respondents were married, and one was single.
Theme 1—experiences with online booking
The service provider mentioned that the online booking system was announced on the website, but it did not reach a wide audience. The instruction on how to use the online booking system was displayed on a vinyl poster and placed in the OPD. If patients encountered any difficulties with online booking, the receptionist was available to assist. Online bookings could be made up to one month in advance. The number of online bookings was limited each day, and patients were notified whether their requested appointment was available. So that they could adjust their appointment date accordingly.
Most of the respondents indicated that the online booking system is simple, easy to use, and more convenient compared to their previous experiences.
“…We are comfortable using it. It’s simple to use. I took a photograph of the instructions. When I got home, I followed the steps, and it was convenient. It was easy to do.” (28 years, middle school passed, male).
“…Before there was no booking system, I had to arrive early and wait, waking up at 5 a.m. It costs a lot of time and effort. Now, with just a phone, it’s much easier. The patient can be brought in promptly. In the past, there were occasions when I had to wake up as early as 4 a.m. If I arrive at 5 a.m., I had to return home without receiving healthcare because the place was crowded. Now, it’s much more convenient.” (30 years, high school passed, female).
“It is quite good. People from distant places arrive early in the morning with their luggage and stand in line for a long period. Now, they can schedule appointments online and arrive at the designated time.” (30 years, high school passed, female).
“As soon as I am discharged from the hospital, I book online for my follow up. I got the appointment on the day I wanted. It is great!” “As I book online, there’s not much waiting for the follow-up visit. It’s really convenient!” (69 years, graduate, female).
On the other hand, some patients prefer the telephone booking system due to internet connection problems.
“Telephone booking will be easier. It’s convenient, especially for follow-ups when online booking is not available.” (36 years, primary school passed, male). The service provider side stated that the online booking system improves the quality of services due to various reasons.
“Before, there used to be a long queue to get a token for an outpatient appointment. It was a complicated process with about 4–5 workers involved. Now, patients who book online don’t need to queue, so the line is shorter, and there are fewer arguments. The workers are less stressed. Extra workers have been reassigned to tasks like recording fevers and taking blood pressure. This leads to better-quality service.” (54 years, medical superintendent, female).
Theme 2—challenges with online booking appointments
Several respondents reported some challenges in using an online booking system. The main challenges are a lack of resources, technical skills, internet connection problem and charges.
“It is inconvenient for some people. Some from rural areas have challenges in using phones or making online bookings.” (28 years, university student, female).
“It is beneficial for individuals with skills. However, it can be challenging for older individuals who lack technical skills.” (69 years old, graduate, female).
“Patients don’t want to do online booking. Sometimes the health staff are asked to help. Their relatives, who are more familiar to using phones, help with the online booking process.” (52 years, nurse, female).
“Most of the patients don’t know how to use the phone. Their phones don’t have Viber software, and they are unfamiliar with what Caremebot is. They struggle to fill in the information, which is quite challenging. Even now, I still have to assist with many tasks. Even when they receive the booking number, they don’t know how to proceed.” (26 years, receptionist, male).
“ .. It’s not that difficult. Sometimes, I have to wait. If the internet is slow, I have to wait for a while to get confirmation. Of course, it costs for the internet.” (30 years, high school passed, female).
The provider side also stated the main challenge for adopting an online booking system as the sole method for outpatient appointments.
“Some people just don’t accept it. They can’t handle such a big change. The main problem is resistance to change.” “Previously, we established that OPD appointments would only be accepted through online booking. However, this approach was inconvenient, and many people still prefer the traditional walk-in system.” (54 years, medical superintendent, female).
Theme 3—suggestions for improvement to the online booking system
There are several suggestions for improving the online booking system, with a particular focus on promoting its use via mass media and providing guidance for individuals who may lack technical skills.
“Information sharing about online booking should be done. The instructions need to be clear so that older people can easily understand.” (69 years old, graduate, female).
“Information sharing should be done. You should instruct the elder persons how to do it.” (39 years, specialist, male).
“It will be necessary to provide descriptions in newspapers and collaborate on social media. Success will come if patients understand that the process is not challenging.” (54 years, medical superintendent, female).
Discussion
YGH is a 2,000-bedded specialty hospital, and it is also a tertiary care teaching hospital. The cross-sectional descriptive study was conducted to assess the OPD’s online booking appointment system at YGH. The online booking system of YGH was initiated on 1st February 2022. The introduction of online booking aimed to minimize physical contact during the pandemic, prevent overcrowding due to walk-ins, and reduce waiting times.
Over the 6-month study period, approximately one-third of outpatients utilized the online booking system. The study conducted by Samadbeik revealed a comparable outcome, indicating that the outpatient appointment system in Iranian hospitals primarily relies on the traditional walk-in approach rather than the online booking system (2).
A total of 179 respondents who used the online booking system of the specialist OPD in YGH participated in this study. In this study, about 20% of respondents were 56–65 years age group, and 62% were female. This study involves the relatively older population compared to the similar study (4-6).
As per the findings, two-thirds of the outpatients were from urban areas, and most of the respondents were dependent, reflecting similar findings in a Chinese study (7). In the current study, two-thirds of the respondents had middle and lower education levels, showing a lower education level of participants compared to other studies (4,8). Generally, individuals with middle and low education status and a lower socio-economic status tended to use public healthcare settings, while those with a higher socio-economic status were more inclined to use the private sector. The higher percentage of respondents with a low education status in this study may be attributed to the fact that the study area is a public hospital.
Regarding online booking, over 90% of the respondents believed that the use of the operating system was user-friendly. Similar results were found in a study conducted in China, where 81.9% of the respondents considered online appointments convenient during the pandemic (7). Most of the respondents expressed satisfaction with the online booking system in this study. However, the qualitative findings indicated that elderly patients, patients from remote areas with no internet access, and those who are not accustomed to using mobile phones encountered difficulties in utilizing the online booking system.
Regarding OPD services, almost all patients were satisfied with the overall services, with doctors’ communication, nurses’ communication, and the availability of an adequate waiting area being the most satisfying aspects. A similar result was found in an Indian study where the behaviour of nurses, doctors, and orderlies satisfied 92%, 92%, and 83% of people, respectively (9). Almost all patients expressed satisfaction with specialist OPD services in the current study. In Iran study, only 43.7% of respondents were satisfied with their OPD services (10). YGH is the largest specialist hospital in Myanmar, and its services and infrastructure are significantly better than those of other public hospitals. This could be a reason for the very good satisfaction of patients with the OPD services at YGH.
Despite the good satisfaction exhibited by patients in the quantitative study, participants outlined some challenges in using the online booking system during IDIs. The systematic review on web-based medical appointment systems stated that the resistance in using web-based appointments was mainly related to past experiences with computers and the Internet, as well as individual communication preferences (10).
The primary difficulty reported in this study was a lack of technical skills. Many patients attending the OPD of YGH have lower levels of education, and they come from various regions across the country, including remote areas. Some patients are unfamiliar with using phones, and as a result, encounter difficulties with the online booking system. It was noted that individuals accustomed to using phones have no difficulty in using the online booking system. Regarding the provider side, the study of web-based application systems found that the barriers to providers adopting web-based scheduling include concerns related to cost, flexibility, safety, and integrity (11). In this study, most of the providers are willing to use the online booking system even though this was their very first experience of using it. The major challenges for providers were to provide information about the online booking system and help teach the patients how to use it. The healthcare providers recommended advocating to the public about the online booking system and how to use it through mass media, social media, and all possible channels to promote public awareness and cooperation.
Conclusions
As a newly implemented program, patients’ response to the online booking system is positive. However, there are some additional issues to address for better implementation. It is advisable to provide information to the public regarding the utilization of the online booking system through mass media. This online booking system is highly effective for both service providers and patients, reducing waiting times and enhancing the quality of services. It is recommended the extension of this system to other public hospitals in Myanmar, particularly in tertiary hospitals with a significant patient load.
Limitations of the study
We only selected outpatients who used the online booking system. Individuals with a negative experience with the online booking system may choose the traditional walk-in system and could be excluded from this study. Therefore, our satisfaction level might be an overestimation. The patients who have difficulty using the online booking system did not get involved and so some challenges could be missing in this study. Our study was conducted 7 months after the implementation of the online booking system. Some difficulties may have been identified and corrected during this period.
Acknowledgments
We would like to express our gratitude to all responsible persons from Ministry of Health and YGH who granted us the opportunity to conduct this study and supported us during data collection and interviews. Additionally, we extend our thanks to ChatGPT for its assistance in grammatical correction during the writing process.
Footnote
Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-23-168/dss
Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-23-168/prf
Funding: This research was funded by
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-23-168/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of the Department of Medical Research (Ethics/DMR/2023/002) and informed consent was obtained from all individual participants.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Aye KC, Htwe SH, Aung S. Assessment of outpatient department online booking system at Yangon General Hospital. J Hosp Manag Health Policy 2025;9:18.
