Original Article

Healthc Inform Res. 2017 January;23(1):35-42.

https://doi.org/10.4258/hir.2017.23.1.35
pISSN 2093-3681 • eISSN 2093-369X

Application of Queueing Theory to the Analysis

of Changes in Outpatients’ Waiting Times in
Hospitals Introducing EMR
Kyoung Won Cho, PhD1, Seong Min Kim, BS1, Young Moon Chae, PhD2, Yong Uk Song, PhD3
1
Department of Healthcare Administration, Kosin University, Busan, Korea; 2Graduate School of Public Health, Yonsei University, Seoul, Korea; 3Division of
Business Administration, Yonsei University Wonju Campus, Wonju, Korea

Objectives: This research used queueing theory to analyze changes in outpatients’ waiting times before and after the intro-
duction of Electronic Medical Record (EMR) systems. Methods: We focused on the exact drawing of two fundamental pa-
rameters for queueing analysis, arrival rate (λ) and service rate (μ), from digital data to apply queueing theory to the analysis
of outpatients’ waiting times. We used outpatients’ reception times and consultation finish times to calculate the arrival and
service rates, respectively. Results: Using queueing theory, we could calculate waiting time excluding distorted values from
the digital data and distortion factors, such as arrival before the hospital open time, which occurs frequently in the initial
stage of a queueing system. We analyzed changes in outpatients’ waiting times before and after the introduction of EMR us-
ing the methodology proposed in this paper, and found that the outpatients’ waiting time decreases after the introduction
of EMR. More specifically, the outpatients’ waiting times in the target public hospitals have decreased by rates in the range
between 44% and 78%. Conclusions: It is possible to analyze waiting times while minimizing input errors and limitations
influencing consultation procedures if we use digital data and apply the queueing theory. Our results verify that the introduc-
tion of EMR contributes to the improvement of patient services by decreasing outpatients’ waiting time, or by increasing ef-
ficiency. It is also expected that our methodology or its expansion could contribute to the improvement of hospital service by
assisting the identification and resolution of bottlenecks in the outpatient consultation process.

Keywords: Electronic Medical Record, Healthcare, Queue, Waiting Time

I. Introduction
Submitted: November 2, 2016
Revised: January 24, 2017
Accepted: January 25, 2017 Hospitals are doing their best to provide a variety of medical
services to increase patients’ satisfaction. In particular, they
Corresponding Author have introduced Electronic Medical Record (EMR) systems
Yong Uk Song, PhD
to enhance their business efficiency and the quality of medi-
Division of Business Administration, Yonsei University Wonju Cam-
pus, 1, Yeonsedae-gil, Heungeop-myeon, Wonju 26493, Korea. Tel: cal services [1]. However, public hospitals, which are less
+82-33-760-2340, E-mail: [email protected] competitive than private hospitals, are one step behind in in-
troducing EMR. Therefore, the Korean government has be-
This is an Open Access article distributed under the terms of the Creative Com-
mons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- gun to implement EMR systems in public hospitals, such as
nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited.
Incheon Medical Center [2], Busan Medical, Gunsan Medi-
cal Center, and medical centers in the Gyeongbuk region [3].
ⓒ 2017 The Korean Society of Medical Informatics
It is known that the introduction of EMR has the effect of
Kyoung Won Cho et al

reducing outpatients’ waiting times [4]. Many changes in Section II addresses queueing theory and explains our pro-
business process regarding chart management have been prietary method to calculate waiting times. Section III ana-
reported because there is no need to deliver charts manually lyzes changes in outpatient waiting times before and after the
from storage to the medical office with the introduction of introduction of EMR in some Korean public hospitals, which
EMR. Hence, there is a need to investigate how much pro- were calculated by the proposed method. Finally, Section IV
cessing time is reduced in departments influenced by the discusses some implications of our findings and draws some
introduction of EMR. conclusions.
Previous studies regarding waiting time in medical services
have focused on doctors and patient consultations in general II. Methods
hospitals [5]. Such studies found that the factors influenc-
ing consultation and waiting times are medical providers’ To investigate changes in outpatient waiting times before
characteristics, characteristics related to consultation, and and after the introduction of EMR by applying queueing
patients’ characteristics [6] as well as consultation depart- theory, we review queueing theory briefly and then explain
ment, whether a patient had an appointment or not, whether our approach to examine outpatients’ waiting times, which
the patient was a new outpatient or not, patients’ perceived includes data collection and the calculation of arrival and
consultation waiting times, patients’ endurable waiting times service rates.
[7], and so forth.
Studies applying queueing theory to medical service can be 1. Queueing Theory
classified into those on waiting time and utilization analysis Patients who want to receive medical services always arrives
[8], those on system design satisfying some conditions re- randomly, and they require immediate services available at
garding queueing [9,10], and those on the relation between that time. If the service facility is operating at peak capacity
appointment systems and queueing. From the perspective of when they arrive, they should wait in line with patience. At
system size, they have been conducted at the levels of the de- this point, according to the difference between the patients’
partment, the healthcare center, and the regional health sys- arrival rate and the time required for services, a queue, in
tem [11]. Studies conducted at the department level include which the patients wait to be served, is formed. Due to the
those conducted at Departments of Internal Medicine [6], characteristics of medical services, it is very difficult to pre-
Orthopedics [8], Emergency Room [12,13], Radiology [10], dict exactly when a patient will arrive and how much time
and MRI [14]. Studies conducted at the healthcare center will be taken for the service. Therefore, the ultimate objective
level include those conducted on a whole outpatient depart- of queueing theory is to achieve an economic equilibrium
ment [5,7,15]. Studies on waiting time and utilization analy- between the service cost and the patients’ wasted time while
sis can be further classified into those on reneging [11,16,17], waiting in the queue to be served. Measurement scales for a
variable arrival rate [18], priority queueing discipline [19,20], queueing system include the average number of customers
and blocking [21]. Studies on system design can be further in its queue (Lq), the average number of customers in its en-
classified into those on blocking [22] and cost minimization tire system including the entity being served (Ls), the average
[23,24]. Studies on the relation between appointment sys- waiting time in its queue (Wq), and the average waiting time
tems and queue include those considering bottlenecks and in its entire system (Ws). The symbols and concepts for a
those on appointment and patient financial services [25]. queueing model are presented in Table 1.
In addition, previous studies on waiting time related to the
introduction of hospital information systems include a study 2. Our Approach
on the reduction of waiting time, which was conducted by We analyze outpatients’ waiting time using digital data,
surveying and investigating a specific hospital [4]. However, such as booking time, blood pressure measurement time,
we could not find any previous studies that have made use of prescription input time, and payment reception time of pa-
queueing theory to investigate changes in outpatient waiting tients who have visited public hospitals. There is, however, a
times before and after the introduction of EMR. Therefore, variety of outpatient consultation paths as seen in Figure 1.
in this research, we investigated changes in the outpatient In particular, since there are cases in which a nurse processes
waiting times before and after the introduction of EMR by several patients’ bookings collectively after consultation
applying queueing theory. without individual booking, as in path 4 in Figure 1, and
The remainder of this paper is organized as follows. First, doctors input prescriptions after payment without booking,

36 www.e-hir.org https://doi.org/10.4258/hir.2017.23.1.35
 Queueing Theory on Outpatient Waiting Time

as in path 5 or 6, we can say that the booking times in the arrival rate (λ) and the service rate (μ), to overcome these
digital data are distorted and cannot reflect the outpatients’ problems. If we know the exact values of the arrival rate and
true waiting times. In addition, if we remove those distorted the service rate, we can calculate the average waiting time in
data with a naive intention to use correct data only, it would a queue (Wq) as in Table 1. Thus, it is possible to measure the
decrease the number of consultations and would result in the decrease in outpatients’ waiting times before and after the
underestimation of measurements, including waiting time, introduction of EMR.
number of customers in the queue, and so forth. Almost all queueing models assume the probability distri-
We focus on the exact drawing of two fundamental param- bution of the interarrival time and the service time as an ex-
eters from the digital data for queueing analysis, namely, the ponential distribution, and the number of arriving patients
per unit of time follows Poisson distribution. Therefore, we
Table 1. Symbols for queueing model and calculation in M/M/1 assume that the probability distributions of the interarrival
model and service times are exponential. Furthermore, because
the purpose of this research was to analyze the change in
Calculation in
Symbol Definition outpatients’ consultation time in terms of a hospital and as
M/M/1 model
a result, the number of the server is one in this case, we use
n Number of customers in a system
the queueing model of M/M/1 for the analysis.
λ Average arrival rate (e.g., number of
arrivals per hour)
1) Data collection
μ Average service rate per server (e.g., We collected digital and observation data from three public
1/average service time) hospitals that had introduced EMR systems as part of a local
ρ Operation rate λ hospital information support initiative by the Korea Ministry
ρ=
μ
of Health and Welfare in 2014. These public hospitals intro-
Wq Average waiting time in a queue ρ duced new EMR systems on March 23, March 24, and April
Wq =
μ–λ
13, 2015, respectively. Observers collected data by recording
Ws Average entire time in a system 1 the time when a patient was called and entered the doc-
Ws =
μ–λ
tor’s room and the time when the consultation was finished
Lq Average number of customers in a ρλ and the patient came out of the room. The digital data were
Lq =
queue μ–λ
collected for the weeks during which the observation was
Ls Average number of customers in a λ performed. The digital data were extracted from databases
Ls =
system μ–λ in public hospitals, which existed even before the introduc-

Registration Blood pressure Prescription Payment

Path 1

Path 2

Path 3

Path 4

Path 5

Path 6

Path 7

Figure 1. Patient consultation paths.

Vol. 23 • No. 1 • January 2017 www.e-hir.org 37

Kyoung Won Cho et al

tion of EMR. Patients’ names and gender information were

masked for their privacy, and we used logs of reception times

Observed
and prescription input times in seconds. Basic information

206
98
-

-
on study hospitals for the three public hospitals, namely,
Hospitals A, B and C, are shown in Table 2.

Total

-
-
-
2) Calculation of arrival rate

Digital
There are two ways to calculate the arrival rate. One is to cal-

916
413
-

-
culate the average interarrival times and then take its inverse
number; the other is to take the average number of arrivals,
and these two numbers must be equal. As seen in Table 3,
the difference between the first patient’s arrival time 9:01:10

02/02/2015

07/27/2015
Observed
(arrival 0) and the last patient’s arrival time 9:47:55 (arrival

45
27
10) in data 1 is 46 minutes and 45 seconds or 2,805 seconds.

Hospital C
By dividing the 2,805 seconds by the average interarrival

Jeju
232
31
time of 280.5 seconds, we obtain 10, which is the number of

02/02/2015–

07/27/2015–
02/06/2015

07/31/2015
arrived patients except the first patient or arrival 0.

Digital

226
88
We calculate the arrival rate by using the reception time
as the patient’s arrival time. However, since nurses some-
times process reception collectively in public hospitals, we
can say that the reception time data are distorted, and those
reception times are not exactly equal to the true arrival

02/24/2015

07/14/2015
times. However, the average interarrival time is not changed Observed

75
18
because the interarrival times for other reception times Chungnam
Hospital B

are increased as much when the interarrival times for the

233
21
reception times input collectively by nurses are decreased to

02/23/2015–

07/13/2015–
02/27/2015

07/17/2015
zero. As an example of arrival 6 in Table 3, even though the
Digital

300
133
arrival time 9:43:48 in data 1 is changed to 9:23:48 in data 2,
the average interarrival time is unchanged and maintains the
value of 280.5 seconds. Therefore, there is no change in the
calculated value of the arrival rate. As a result, we can obtain
02/23/2015

07/13/2015

the exact arrival rate from the digital reception time data re-
Observed

gardless of the distortion of the data by collective input.

86
53
On the other hand, consultation time in hospitals includes
Gyeonggi
Hospital A

lunch time from 12:30 to 13:30, and receptions rarely occur

151
16

during lunch time. If we do not consider lunch time and use

02/23/2015–

07/13/2015–
02/27/2015

07/17/2015

the daily reception time data from 9:00 to 17:00 to calculate

Digital
Table 2. Basic information on study hospitals

390
192

the arrival rate, the average interarrival time, which includes

a relatively long interarrival time during lunch time, is over-
estimated. As a result, the arrival rate is underestimated.
Moreover, the total consultation time is 7 hours per day ex-
Round

2nd

2nd
1st

1st

cluding lunch time, while the reception time data include the
data during 8 hours per day, which results in dissonance be-
Number of patients

tween the consultation time period (7 hours) and reception

Number of doctors

time period (8 hours) per day. For this reason, we calculate

Study period

the arrival rate considering lunch time. We divide a day into

Location
Bed size

morning and afternoon, classify the reception data into the

data before 12:30 and the data after 12:30, and we calculate

38 www.e-hir.org https://doi.org/10.4258/hir.2017.23.1.35
 Queueing Theory on Outpatient Waiting Time

Table 3. Calculation of arrival rate

Data 1 Data 2
Arrival Arrival Interarrival Interarrival Arrival Interarrival Interarrival
time time time in second time time time in second
0 9:01:10 9:01:10
1 9:04:07 0:02:57 177 9:04:07 0:02:57 177
2 9:04:17 0:00:10 10 9:04:17 0:00:10 10
3 9:11:24 0:07:07 427 9:11:24 0:07:07 427
4 9:11:33 0:00:09 9 9:11:33 0:00:09 9
5 9:18:52 0:07:19 439 9:18:52 0:07:19 439
6 9:43:48 0:24:56 1,496 9:23:48 0:04:56 296
7 9:44:15 0:00:27 27 9:44:15 0:20:27 1,227
8 9:44:29 0:00:14 14 9:44:29 0:00:14 14
9 9:45:31 0:01:02 62 9:45:31 0:01:02 62
10 9:47:55 0:02:24 144 9:47:55 0:02:24 144
(avg) 280.5 (avg) 280.5

interarrival times for each set of data separately. Using the digital data in hospitals, so we used the observation data for
entire data for the dates when we collected the data, we cal- consultation time acquired by an observer who actually vis-
culate the average interarrival time and, finally, we calculate ited public hospitals and carried out the observation work.
the arrival rate. This arrival rate is exactly equal to the aver- However, since we could not find a statistical significance in
age number of arrivals for the mornings and afternoons of using the observation data due to its limitation in the num-
the dates when we collected the data. ber of the data, we use those observation data just for sup-
port. That is, instead of obtaining the service rate by averag-
3) Calculation of service rate ing the observed consultation times, we used the maximum
Digital data in hospitals usually do not include a patient’s of the observed consultation times to identify outliers, and
consultation start time and finish time. The consultation, we averaged the consultation time from the digital data in
however, finishes with prescription input, so we use the hospitals after excluding the consultation times of which the
prescription input time as the consultation finish time. Nev- value was greater than the maximum observed consultation
ertheless, there is no consultation start time in the digital time. After that, we used the inverse number of the average
data. However, when a doctor treats patients in succession, as the service rate.
a patient’s consultation start time is the previous patient’s We carried out a t-test to verify whether there was any dif-
consultation finish time, so we can use the previous patient’s ference between the service rates obtained from the digital
consultation finish time, that is, prescription input time, as and observed data (Table 4). Since we were able to conduct
the patient’s consultation start time. In other words, the time observation during just one day, we used digital data for the
period between a patient’s prescription input time and his/ same day of observation. The differences between the aver-
her previous patient’s prescription input time is the consul- age service rates were 67.47 and 14.9 in the first and second
tation time or service time for the patient, and the inverse investigations in Hospital A, 12.68 and 25.37 in Hospital B,
number of the average consultation time is the service rate. and 65.66 and 58.06 in Hospital C. We found that there was
The important point here is that we must exclude the data no statistically significant difference between the service
for cases in which the doctor does not treat patients in suc- rates obtained from digital and observed data except in the
cession and a patient’s consultation start time is not equal to first investigation in Hospital A, where the service rates from
the previous patient’s prescription input time. Considering the digital and observed data were statistically significantly
these cases, we calculate the service rate by excluding the different with the p-value of 0.001. Although we cannot ar-
outlier data among those service times. In this study, how- gue the consistency of the service rates statistically because
ever, it was impossible to identify the outlier data from the only six comparison data sets were considered, we may claim

Vol. 23 • No. 1 • January 2017 www.e-hir.org 39

Kyoung Won Cho et al

Table 4. The t -test for service rate

Hospital A Hospital B Hospital C

Round Type
Mean SD t (p -value) Mean SD t (p -value) Mean SD t (p -value)
1st Digital 186.15 122.479 3.541 128.42 89.896 0.848 221.76 196.236 1.621
Observed 118.68 95.821 (0.001) 115.74 66.388 (0.399) 156.10 110.511 (0.113)
2nd Digital 92.25 103.730 –0.800 155.78 118.707 0.538 190.23 143.808 1.381
Observed 107.15 79.510 (0.426) 130.41 128.553 (0.593) 132.17 96.603 (0.188)

Table 5. Changes in outpatients’ waiting time

Hospital A Hospital B Hospital C Total

Round Variable
Digital Observed Digital Observed Digital Observed Digital Observed
1st Average consultation time 0:02:52 0:01:59 0:02:24 0:01:56 0:03:23 0:02:36 0:02:51 0:02:10
a
Maximum consultation time 0:08:30 0:05:49 0:11:13
λ 11.741 12.378 9.933 12.233 8.250 8.324 9.975 10.978
μ 20.873 30.333 25.070 31.104 17.697 23.062 21.213 27.655
ρ 0.562 0.408 0.396 0.393 0.466 0.361 0.470 0.397
Wq 0.062 0.023 0.026 0.021 0.049 0.024 0.042 0.024
Waiting time (sec), A 221.746 81.813 94.234 75.025 177.644 88.163 150.620 85.690
Ws 0.110 0.056 0.066 0.053 0.106 0.068 0.089 0.060
Lq 0.723 0.281 0.260 0.255 0.407 0.204 0.417 0.261
2nd Average consultation time 0:02:25 0:01:47 0:02:48 0:02:10 0:04:10 0:02:12 0:03:04 0:02:03
a
Maximum consultation time 0:06:35 0:07:09 0:09:23
λ 6.289 7.890 4.985 3.607 4.081 4.630 5.119 5.376
μ 24.798 33.599 21.440 27.606 14.423 27.238 20.221 29.211
ρ 0.254 0.235 0.233 0.131 0.283 0.170 0.253 0.184
Wq 0.014 0.009 0.014 0.005 0.027 0.008 0.017 0.008
Waiting time (sec), B 49.331 32.881 50.872 19.601 98.494 27.071 60.344 27.795
Ws 0.054 0.039 0.061 0.042 0.097 0.044 0.066 0.042
Lq 0.086 0.072 0.070 0.020 0.112 0.035 0.086 0.042
b
Decrease rate (%) 77.75 59.81 46.02 73.87 44.56 69.29 59.94 67.56
a b
Cutting criteria. Decrease rate = (A – B) / A × 100.

that the service rates from the digital and observed data were namely, Hospitals A, B and C.
similar to each other and the service rates obtained from We carried out queueing analysis for outpatients’ waiting
digital data, which were based on huge data sets, were more times before and after the introduction of EMR and inves-
accurate than the service rates obtained from observed data, tigated the changes in waiting time (Table 5). In the case of
which were based on a limited number of data sets. Hospital A, the patients’ average waiting times in a queue
were 221.75 and 49.33 seconds before and after the introduc-
III. Results tion of the system, for which the decrease rate was 77.75%.
In the case of Hospital B, the patients’ average waiting times
We analyzed the changes in outpatients’ consultation waiting in a queue were 94.23 and 50.87 seconds before and after the
times before and after the introduction of EMR by apply- introduction of the system, for which the decrease rate was
ing the proposed method to calculate the waiting times. We 46.02%. In the case of Hospital C, the patients’ average wait-
obtained and compared outpatients’ waiting times before ing times in a queue were 177.64 and 98.49 seconds before
and after the introduction of EMR in three public hospitals, and after the introduction of the system, for which decrease

40 www.e-hir.org https://doi.org/10.4258/hir.2017.23.1.35
 Queueing Theory on Outpatient Waiting Time

rate was 44.56%. We obtained the waiting times from ob- resolve bottlenecks in the outpatient consultation process.
servation data as well to verify the decrease in waiting time
obtained from digital data; thus, we could confirm that the Conflict of Interest
outpatients’ waiting times decreased after the introduction of
EMR. The average waiting time in all of the three hospitals No potential conflict of interest relevant to this article was
were 150.62 and 60.34 seconds before and after the introduc- reported.
tion of the system, for which the decrease rate was 59.94%.
Acknowledgments
IV. Discussion
This research was supported by the “Performance evaluation
We analyzed the changes in outpatients’ waiting times be- program of information systems for the regional public hos-
fore and after the introduction of EMR using the proposed pitals” funded by the Ministry of Health and Welfare.
method. According to the analysis result, the outpatients’
waiting times in three public hospitals decreased after the in- References
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