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Key Points


* Trello is a cloud-based, project management system that is based on boards, lists, and cards.


* The Portland Community Free Clinic developed a novel system using Trello to manage appointment scheduling, maintain their volunteer provider database, and keep track of pending items such as laboratory results and referrals.


* Trello works on multiple platforms allowing staff to view schedules and activity outside the office, but the system is private and secure and available only to authorized users.


The Portland Community Free Clinic (PCFC) is a volunteer model clinic that provides primary healthcare to uninsured adults residing in Cumberland County, Maine. Since its inception in 1993, the PCFC has always relied on the generosity of donors to support its ongoing operations. Thus, we are masters of finding ways to do things for free or at a very low cost. Our appointment and scheduling system, created with Trello, is no exception.


Our documentation and data storage systems mix paper and electronics in a hybrid way that meets our needs, but we are always open to find ways to be more efficient and streamlined. Charting is done on paper, but patient information (demographics, diagnoses, encounters) is stored in a homegrown Access database. All records related to Patient Assistance Program medications are also kept in Access.


Up until March 2014, all appointments were written in pencil on pages for individual days that were stored in a 3-ring binder. This was the one system in the PCFC that had no redundancy and I, as coordinator, worried about the consequences if the notebook were to become lost or destroyed. For approximately 2 years, I had been searching-without success-for a computer-based system that would allow us to more flexibly maintain our schedule, be automatically backed up, provide greater access for staff and volunteers, and perhaps most importantly fit our shoestring budget.



Because appointments are scheduled by date, most people (myself included) immediately think of using a calendar for scheduling. The problem with this, as I quickly discovered, is that most calendars are "people oriented." If you have a team of 10 people it might be possible to juggle 10 calendars. But the PCFC has 100+ volunteers, many of whom work one evening/month for just 2 to 3 hours. Having calendars for all of our volunteers was not feasible. I spent a long time thinking about (and playing with) calendars and trying to conceptualize them differently, to no avail.


My next approach was to look at scheduling systems, some of which were specific for healthcare settings, whereas others were more diverse, including salons and spas. Most programs offer a free trial so I took advantage of those. It did not take long for me to discover if a program was not a good fit, which was usually the case. Two common problems I came across: (1) there was emphasis on marketing and sales, offering conveniences such as a user (in our case, a patient) scheduling an appointment through a Web interface. Although this sounds nice, we have volunteers with a wide variety of expertise so scheduling appointments appropriately is a bit of an art. Also, patients do not know all our providers, so it would not be realistic for them to schedule their own appointments to be seen. (2) For healthcare programs, there was an emphasis on integrating with insurance and payment systems; because we are a free clinic (all of our services are offered at no cost), insurance is not relevant to our situation. Also, most of these programs were designed for offices with a handful of providers and could not accommodate our large number of volunteers.


As I evaluated different programs, I paid attention to customer service (were e-mails answered?) and an assessment of whether the developer seemed to be a going concern that would be around for more than a few months. I was also always mindful of cost, but this was usually my last criteria for selection. No application that I evaluated worked for us, until I discovered Trello.



Every month, more or less, I would Google "scheduling system," "organizer," or some other combination of similar words. I do not remember exactly what terms I used on March 7, 2014, but I suddenly stumbled upon Trello. First I watched a video,1 then I read a blog from Trello founder, Joel Spolsky.2 His comment in the blog-that people use Excel for creating tables, not for calculations-made a light bulb go off in my head. We kept track of our volunteer schedule for the next 2 weeks on a white board. Trello is a board with lists and cards. Could we reconceptualize our scheduling system, which was scattered across two notebooks, a white board, and various Excel files into one system using Trello? The answer was ultimately yes.


I immediately registered an account and began playing around with Trello. The program is fun to use, so this made the "learning curve" part of the process enjoyable. Trello is also very simple, which was important for the PCFC team who were not known for embracing technology!


Trello consists of three elements: boards, lists, and cards. There is no limit to how many boards you can create, how many lists are on a board, and how many cards are on a list. I saw very quickly, however, that if a list was too long and scrolled off the screen downward it was not useful. Likewise, too many lists on a board that scrolled off the screen sideways were cumbersome. Therefore, in my experimenting, it became clear that we would need more than one board to organize our system. That was my starting point.


I then thought about the elements of our current system. We had the following:


* a white board, which listed the volunteers scheduled for the next 2 weeks, by date;


* the appointment book, which listed volunteers, by date, for up to 3 months; appointment slots were included for each volunteer on their scheduled day; and


* Excel spreadsheets, which were updated regularly and printed with every update; these sheets listed volunteer providers by name with contact information (various phone numbers and e-mail address).



I spent the better part of a weekend trying to reconceptualize our existing system into Trello. There are lots of examples of Trello boards online, but no one seemed to be using the program the way I envisioned. Projects revolved around planning events (such as a wedding) and "to do" lists (getting a book written) but not a system to organize people (providers and patients) and appointments.


Note what I said about how much time I spent on this: a weekend. The system I developed in approximately 2 days has been remarkably stable and has required only minimal tweaks since it was first developed-now going on 2 years. I think this is evidence of how easy Trello is to use.


The PCFC Trello System

The starting point for our first board became a combination of the white board and appointment book, which was named Two Week Schedule (Figure 1). Our second board, Big Picture Overview, is a combination of the appointment book and the provider lists in Excel (Figure 2). Our third board, Provider List, is analogous to a file box of index cards. Like index cards, Trello cards can have writing on the front and back. Figure 3 illustrates the back of a fictional provider's card, with contact information, a checklist for their preferred schedule, and any other relevant information, such as best days for volunteering. Checklists are a nice, built-in feature, and we use them liberally on provider cards. They are the core of making patient appointments. Types of providers are color-coded with green for primary care, orange for psych, purple for nurses, and so on. Likewise, the background colors for the boards have become very familiar to all of us so we know immediately which board we are looking at: green for Two Week Schedule, blue for Big Picture Overview, and red for the Provider List.

Figure 1 - Click to enlarge in new windowFIGURE 1. Two week schedule.
Figure 2 - Click to enlarge in new windowFIGURE 2. Big picture overview board.
Figure 3 - Click to enlarge in new windowFIGURE 3. Example of a provider card.

Big Picture Overview was a bit of a challenge for the staff, at first, because they were used to seeing the schedule by date, not by type of provider. However, there is a toggle to switch to a calendar view, which can be seen in Figure 4. This quelled their desire to reorganize the board by date.

Figure 4 - Click to enlarge in new windowFIGURE 4. Illustration of the calendar view.


We strive to have volunteers scheduled 3 months in advance, which allows us to schedule patient appointments that far out-more than 3 months, they need to call us (more on this later). The volunteer coordinator (VC) still sketches out the schedule on paper, but once she is ready to "Trello-ize" the schedule, she starts on the provider board. Key to the system is the fact that cards and lists can be moved or copied from board-to-board. From the Provider List, the VC copies (not moves) a provider to the Big Picture Overview. By copying, the card is resident in two places (Provider List and Big Picture Overview). Copying also ensures that all the information on the card, both front and back, stays put.


When the card is copied to Big Picture Overview, the VC then adds a due date, which is the scheduled date for the volunteer at the PCFC. The due date is necessary because that is what makes the calendar view (Figure 4) work. You will also notice on Big Picture Overview (Figure 2) that the cards are organized on the lists by date. Unfortunately, this does not happen automatically. Cards are easy enough to move, but it does require an extra step. We have discovered that it is best to have cards in date order, to facilitate finding a provider and adding an appointment to the schedule. A requested fix is to have cards sort automatically by due date, or at least give the user the option to make this happen.


While cards are copied from the Provider List to Big Picture Overview, they are moved to the Two Week Schedule as the date draws near. This takes the card off the blue Big Picture Overview calendar and puts it on the green Two Week Schedule calendar. We do not want a card in two places, in this circumstance. The Two Week Schedule is closest to our old white board, but it has value-added features: scheduled appointments and provider contact information.


Trello cards allow team members to share information through comments. We use this feature to keep track of e-mail, phone calls, and other tidbits of information that relate to a provider, the schedule, and patients.


Once a date has passed, we archive the list. Archived lists are maintained within Trello, so we can go back and search for a provider or patient. Unfortunately, archived lists and cards are not very well organized, so it can feel like sifting through a pile of trash to find something.


A Surprise Board

The original system of three boards was derived from our traditional workflow. We knew we always struggled with keeping track of and following up on a variety of items, such as receiving laboratory and x-ray results and following through on referrals. We also never had a good way to keep track of notes, such as extended vacations for providers. We had an "Aha!" moment when we created a To Do/Pending Board to manage all this information. To make this work, we realized we need to check the board daily and update/archive cards as necessary. For me, an important measure of success is that we have not lost track of a Papanicolaou smear in the time since we implemented the system, something that happened much too frequently before. Also, remember what I said earlier about patients needing to call us for appointments beyond 3 months? We are able to track these pending appointments on the To Do/Pending Board and contact patients to schedule an appointment when the provider's schedule is available. This has improved our patient follow-through and continuity.



Overall, we believe our Trello system is a success. The first thing that disappeared from the old system was the white board, followed by the constantly updated Excel spreadsheets for provider contact information. We do maintain the sheets, just because we like having redundant information, but they are not printed all the time and stored in notebooks.


We have not been able to eliminate the paper appointment book-that is still a mainstay of our scheduling. It takes regular reminding (on everybody's part) to make sure that an appointment written in the book gets recorded in Trello and vice versa. It can be confusing when something is recorded in one place but not the other, and there is no documentation in the chart as to what is correct.


Trello is cloud based and works across multiple platforms, including smartphones and tablets. I only work at the PCFC 2 days/week, so I like being able to keep an eye on what is going on, even when I am not on site. The VC likes to be able to do the process of copying and moving cards from the various boards when she is at home and it is quiet, versus being at the PCFC with constant interruptions and ringing phones.


One frustration, for which Trello has not been responsive to our requests, is the way checklists are handled. As noted earlier, we use checklists extensively to schedule appointments. When an item is added to a checklist (in our case, an appointment is scheduled), if it is checked, the item becomes italicized and crossed off. However, on the iPad version of Trello, a checked item only goes into italics, and this is the functionality that we have requested for the desktop version. The reason: a summary of the checklist is shown on the front of cards, which allows us to see how many appointments a provider has scheduled or available. If you look closely in Figure 2, you can see items such as "3/5" or "1/4," which indicates the number of appointments available (the denominator) and the number of appointments scheduled (numerator). An item must be checked for the numbers to show on the front, which means we are reading scheduled appointments through crossed-out lines. This seems like a simple fix that we wish would be implemented.


We upgraded to Trello Business Class in the summer of 2014, which allows us to have team members who can do everything (create boards, lists, and cards and move everything around) and observers. Team members cost $100 per year per member (we have five, so $500), whereas observers are free. Our plan is to develop an orientation for our volunteers and add those who are interested in accessing the system as observers. That way, a volunteer can see his/her schedule in advance, including day scheduled and number of patients to be seen.



After a long and fruitless search of various calendars and scheduling programs, Trello has become a workable solution for scheduling appointments and providers for our volunteer model clinic. In addition, creating a To Do/Pending Board has made us more efficient in keeping track of tests and referrals for our patients. Through careful implementation of the system, we have been able to eliminate some of older, time-consuming processes and are more responsive to provider requests for schedules and updates. Even paying for business class, Trello is still cost-efficient, easy to use, accessible, and secure.



The author thanks the Allagash Community Foundation for its grant, which allowed the PCFC to buy Chromebooks and upgrade to Trello Business Class.




1. FogCreekSoftware. Trello. Organize anything, together. September 2011. Accessed October 6, 2015. [Context Link]


2. How Trello is different-Joel on Software. Accessed October 6, 2015. [Context Link]