How about your tantrum at 2:30 p.m. on Friday?

"How about the 1st at 10:30 a.m.?"

"No. How about 2:30 p.m.?"

"The 5th at 1 p.m.?"

"No. How about the 9th at 9 a.m.?"

"At 11 a.m.?"

"No."

"The 15th at 3:30 p.m.?"

"Yes! The whole day is wide open."

"Thank God. I thought we were never going to . . ."

"Oops. That's a holiday."

"This is ridiculous. I have my daily calendar right here. Let me just look at the schedule you have on your computer screen, and I'll be able to see what will work. It will save us both a whole lot of time."

"We can't do that. We can't have you see other clients' names."

"Sigh! The 19th at 11 a.m.?"

"No. How about the 20th at 2 p.m.?"

"The 21st at 10:30 p.m.?"

"No. How about the 22nd at 7:30 a.m.?"

"I can't take this anymore. Just let me look at that freaking computer!"

"Back off! Do you think this glass screen is a medical receptionist's version of a salad bar sneeze guard? This is two inches of bulletproof glass installed to keep terrorists like you from HIPAA-protected healthcare information. So, unless you want to experience the most intense body cavity search ever by Homeland Security, I suggest you step back."

"Okay, okay. The 25th at 8:30 a.m.?"

"No. How about the 27th at 8:30 a.m.?"

"That's a Saturday."

"Yes, we have Saturday hours now for the convenience of our patients."

"What would be more convenient would be if this glass wasn't bulletproof because I have a . . ."

"SECURITY!"

Are your patients more sophisticated than your radiology practice? I feel that way whenever I deal with my own doctors. I do all of my professional radiology work online. I buy food, books, clothes, stocks, even insurance online. I schedule vacations online: airline tickets, hotel rooms, and rental cars. On the cruises I take, I can schedule shore excursions online.

So why can't I schedule a doctor's appointment online? The whole scenario above plays out every time I try to schedule an appointment with any doctor, dentist, or lawyer. All of them have computer-based scheduling programs, but those programs are not designed for online access. Why not?

With only a little bit of research, I found that, in fact, numerous companies make products that allow online scheduling. These programs are used not only by medical offices and hospitals but also beauty salons, health clubs, spas, consulting services, and even massage parlors. If only they could develop a program to allow you to get a massage online.

A number of hospitals, clinics, and doctor's offices will allow you to schedule an appointment online-just not mine. But they don't allow radiology scheduling online. Many facilities will allow you to request an appointment online, but you cannot actually schedule it that way. The Florida Hospital system will let you request an imaging appointment online, but then you have to wait to get a call back to actually schedule it. After playing phone tag, you could very well get, "I'm sorry, but the 3rd at 9 a.m. won't work. How about the 4th at 10 a.m.?" "No. How about . . . ?"

One argument I get for why you can't do radiology scheduling online is that you need to have a doctor's order, otherwise patients would be ordering studies willy-nilly on themselves. Yet in my previous practice, a patient had only to call up and say he or she had a request, and we would schedule that person right then and there. We would then just ask the patient to bring along the doctor's order. If it was complicated or expensive study like an MR or CT, we would ask the patient to fax the request. If we didn't get it, we would call the doctor's office to get it.

This could all be accomplished just as easily online. A simple box patients could click saying they have a doctor's order would have to be checked off before the appointment could be scheduled, or it would require them to fax the request in. Since they would have to provide the ordering doctor's information, if the office never got the fax in a timely fashion, the ordering doctor's office could be contacted.

Safety is the other argument for why you can't do this online, since instructions have to be given to patients. Most safety questions for MR patients are on a questionnaire handed to them when they show up for the appointment. Same for CT. Rather than canceling a study at the last minute, it would be better to get these questions answered online well before the appointment.

If the patient checks a box that is a contraindication to MRI, like an artificial valve or pacemaker, or to CT, such as contrast allergy, asthma, renal disease, or multiple myeloma, the patient could then be instructed that there is a risk and to contact the office in person to schedule the appointment. If the patient answers all the questions in the negative, I am sure some lawyer could come up with an airtight disclaimer, "I have read all the above disclaimers and understand and agree not to hold the radiology practice liable." This could then be checked off just like on so many online contracts.

As for patient instructions? Again, many places just hand a patient a form that says what to do the night before the exam. Numerous sites already on the Web for hospitals and clinics provide patients with detailed instructions, and this informatiion could be added to any online program. Patients could easily be required to click that they have read the instructions, understand them, and agree.

If a group wanted to dip its toes into online scheduling, it could start with mammograms, which do not require a doctor's order. A questionnaire could differentiate between a simple screening mammogram and what might be a diagnostic mammogram that would require a longer time slot. If a patient schedules online, an e-mail reminder could be sent prior to the appointment. Patients are more likely to keep an appointment at a time most convenient for them.

Why does online scheduling matter? Patients are becoming more sophisticated and demanding. "Patient-centric healthcare" is the latest mantra. You can be an early adopter and grab a competitive edge over the group across town or the hospital across the street, or you can fall behind. Keep in mind that major organizations are emphasizing these trends. The 119,000-member American College of Physicians recently put out a policy paper promoting consumer-friendly scheduling.

Your referring clinicians feel the same way. In a study done at Brigham and Woman's Hospital radiology department, published in Academic Radiology in 2003, 75% of referring clinicians who had tried online scheduling preferred it to the telephone. Nonradiology practices that use online scheduling systems not only see a huge drop in missed appointments but also save millions on insurance claim denials. How? The ability to correctly collect all the necessary information for a "clean" claim avoids a rejection by the insurance company.

I am not totally opposed to keeping the current system. There are some clear advantages. Granted Bin Laden still has not been found, but three out of four of my colon polyps missed on regular colonoscopy as well as CT colonoscopy were found by Homeland Security searches after my last clinic outburst over scheduling.

Dr. Trefelner is a radiologist and cofounder of Nightshift Radiology. He invites comments by e-mail at ericxray@pacbell.net or fax at 650/728-5099.