White Paper – A Reasearch Contribution: International Patient Journey Map – Defining and Mapping the Patient Journey of Medical Tourists Seeking State-of-the-Art Treatment Outside Their Home Country

 

Author:
Kevin Bürchler
Swiss Insurance Partners AG
Streulistrasse 19
8032 Zurich, Switzerland
Kevin.Buerchler@swissinsurancepartners.com
+41 44 266 6114

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Management summary

The journey of medical tourists seeking state-of-the-art treatment outside their home country significantly differs from the journey of a national patient. To improve the patient’s experience and satisfaction continuously, it is required to understand better the behavior over this journey from the point of view of the patient.

The international patient journey starts long before a patient schedules an appointment at a particular healthcare provider. Because of the geography’s remoteness, the initial Awareness of the existence of clinics is based on coincidental and random interactions. Additionally, these interactions occur from abroad and therefore remotely, facilitated with the help of digital technology and channels. This applies to the Awareness, the Search, and also the Selection phase of healthcare facilities. An alternative source of information can be either the experiences of surrounding people or information from professional medical tourist agents. Medical tourists inform themselves about the reputation and specialization of medical facilities with the help of the mentioned sources and by reviewing prior-patient feedback.

After having selected a clinic for treatment while still in the home country, the patient travels to the destination country of the clinic to receive treatment. The medical tourist is hospitalized at the healthcare facility for the treatment itself and post-treatment rehabilitation, often including wellness care. However, the completion of treatment is not yet the end of the patient journey of a medical tourist. Patients plan for potentially required follow-up treatment in their home country.

Additionally, following the clinic’s checkout, medical tourists combine their medical treatment with some leisure and tourism activity in the surrounding area of the healthcare facility.

One further element that should not be neglected is insurance-related interactions. These have an impact on the trustworthiness of facilities in the Selection phase and on cost implications after the treatment.

 

1.     Introduction

Medical tourists are individuals seeking medical treatment outside of their home country. The motivations for patients to seek care abroad can be very different. The three main motivation factors may be to benefit from reduced cost, because specific treatment and infrastructure are not available in the home country, or to profit from shorter waiting times (Connell, 2013, p. 8). However, the flow of international patients can broadly be classified into two customer segments. First, individuals from high healthcare-cost locations that seek treatment abroad for a lower price. And second, individuals from countries with a less developed healthcare system who seek more preferential treatment abroad. This investigation will focus on the second customer segment, medical tourists that seek state-of-the-art treatment outside their home country.

Today we know four main pathways of how patients find their way to access healthcare abroad. First, patients that make their own arrangements to travel overseas for treatment. Second, medical tourism arranged by medical tourism agencies and facilitators. Medical tourism agencies are organizations that have specialized in supporting individuals in the process of receiving care outside of their home country. Third, medical tourism that is incentivized by health insurance companies and employers, mainly to reduce healthcare costs as patients receive less expensive care abroad. Fourth, local healthcare providers encourage their patients to receive treatment outside of their home country as a way of medical service outsourcing (Lydia & Frederick, 2011, p. 166).

This research paper focuses on cases where individuals themselves decide to take advantage of the option of medical tourism. Therefore, the pathway one and two.

Despite the growing importance of the medical tourism industry (Medical Tourism Market (By Medical Treatment: Cosmetology, Dentistry, Cardiology, Orthopedic Surgery, Neurology, Oncology) – Global Industry Analysis, Market Size, Opportunities and Forecast, 2018 – 2026, n.d.), Lunt et al. (2011, p. 24) state that while the patient satisfaction is an essential dimension in healthcare, there is yet little known about the medical tourists’ experience and satisfaction. To maintain and improve the experience and satisfaction of international patients, it is required to understand better the journey of a medical tourist, the goals, tasks, interactions, and constraints that individuals encounter when planning for treatment abroad.

This paper examines the journey of international patients that go abroad to benefit from advanced infrastructure and treatments to better understand the behavior of medical tourists. With the help of existing patient journey maps, insights from medical tourism research, and practical knowledge of the author as a subject matter expert, this paper aims to define and map the patient journey of medical tourists seeking state-of-the-art treatment outside their home country.

 

2.     Literature review

Medical tourism

Medical tourism is described by Connell (2013, p. 3) as the idea of patients traveling outside of their country of residence for medical treatment combined with tourism.

The Medical Tourism Association supports this definition and puts greater emphasis on the reasons why patients seek treatment abroad and which sort of treatment is considered to be a medical treatment by defining the term as follows: “Where people who live in one country travel to another country to receive medical, dental, and surgical care while at the same time receiving equal or greater care than they would have in their own country, and are traveling for medical care because of affordability, better access to care or a greater level of quality care.” (Medical Tourism Association, n.d.).

Research yields a wide variety of suggested definitions that may apply to the term “Medical tourism”. Some also suggest differentiating health tourism from medical tourism. Their suggested definitions separate non-invasive from invasive treatments. Invasive treatments abroad that have a long-term effect are categorized under medical tourism. Non-invasive treatments that might include revitalization or wellness procedures are categorized under health tourism (Connell, 2006, p. 1094).

For this paper’s context, the definition of Connell is applied that suggests including all cross-border movements for medical care under the term “Medical tourism”, thus also non-invasive treatments (Connell, 2013, p. 10).

Journey mapping and patient experience

Customer journeys mapping is a tool initially used in marketing to analyze in which moments a customer is most likely to be influenced to buy a product or a service (Court, Elzinga, Mulder & Vetvik, 2009, p.1). A customer journey map is a graphical representation of all interactions between a provider and a consumer, starting with the first encounter and ending with after-sales retention and services. In the report “The Business Case for Customer Journey Mapping” (Econsultancy, 2019, p. 5), the authors conclude that a better understanding of the customer journey is positively correlated with the customer experience. The healthcare industry has taken advantage of this, and several businesses and researchers have started to map the interactions in the journey of a medical patient.

Merlino and Raman (2013, p. 113) say that “The patient experience was everyone and everything people encountered from the time they decide to go to the clinic until they were discharged.” Supporting, but also broadening this definition, Meyer and Schwager (2007, p. 118) define the term as to be the “the internal and subjective response customers have to any direct or indirect contact with the company.” A third extension of the mentioned definition comes from De Keyser, Lemon, and Klaus, which suggests that cognitive, physical, sensorial, spiritual, and social elements are all included in defining a patient experience (2015, p. 23).

Patient journey maps

Philpot et al. (2009, p. 467) have created a patient-centered journey map in their study at the Mayo Clinic to improve the patient experience. They recognized the importance of assessing the full patient journey, not just the actual treatment or appointment. Their study segmented the patient journey into three main chronological categories or stages and mapped the interaction points between the clinic and the patient under each stage. The stage “Away from Mayo” includes scheduling and preparing for an appointment, “At Mayo Clinic” includes checking in, the waiting rooming, the appointment, and checking out. Furthermore, the final stage, “Away from Mayo”, includes follow-up questions or concerns. Under each segment and interaction, the touchpoints between the care provider and the patient have been mapped in further detail.

In their study, Crooks, Kingsbury, Snyder, and Johnston (2010, p. 9) recognized that the patient experience of a medical tourist must be chronologically extended further before scheduling an appointment. Because of a lack of international regulations and the geographic distance between the medical facility and the patient, medical tourists themselves must assess and compare the quality of available medical facilities. Naturally, this must happen already before scheduling an appointment at the selected facility.

In the context of urgent care, Heuser and Nagarajan (2018, p. 11), mapped the patient’s journey to understand the key drivers to retain patients and to understand where in the patient journey a client can be lost. The used model includes the chronologic sequencing of the patient journey into five different stages: Awareness, Search, Select, Experience, and Retain.

Their findings point out the importance of individuals being previously aware of a service provider before searching and selecting a healthcare facility. 43% of patients are lost already in the Awareness stage, a further 46% in the conversion from Awareness to Search because of location inconvenience, because of out-of-network facilities or because insurance companies suggested to the patient another provider.

The organization Switzerland Tourism segmented the customer experience from their business case perspective in order to review what is required to promote medical tourism to Switzerland (Reljic, 2016, p. 4). In their segmentation, they suggested the following sections: Information, decision and preparation, stay in Switzerland, and after treatment.

Following the segmentation, further interaction and action elements were mapped to the respective segments. These elements include interactions from the Switzerland Tourism point of view, as well as from the patient’s point of view.

To conclude the literature review of existing journey maps for international patients: Despite that there is a broad range of different patient journey maps, none of them is qualified and tailored to the specific patient journey of a medical tourist that seeks state-of-the-art medical treatment outside his home country. Further than that, suggested models do not include sufficient detail about interactions for the understanding of how patient experience is built during the patient journey. Crooks et al. (2010, p. 9) confirm this by saying, “Most of what is known about the patient’s experience of medical tourism is, in fact, speculative, idea-based, or anecdotal in nature.” He further suggests that despite some information being speculative or idea-based, specific elements are mentioned regularly in research and thus can be assumed to be widely accepted and correct.

The existing maps will be used as a foundation and completed with further research insights as well as with the author’s expert knowledge to come up with a more complete international patient journey map.

 

3.     Method

This study will address the aim of developing an international patient journey map based on a knowledge synthesis of previous research and proposed patient journey models, applications from medical tourism business, and the knowledge of the author as a subject matter expert. Yet, no primary data will be collected in the scope of this work.

All mentioned journey maps models have their validity. However, they are not fit for the purpose of describing the patient journey of a medical tourist. These journey maps will be regarded as base models to map the customer journey of international patients in greater detail and solely from the patient’s perspective.

 

4.     Analysis

Developing an international patient journey map

Journey map ontology

A journey map ontology defines the main elements of a journey and forms the structure of a journey map, thus suggesting how the concept of a patient journey map should look. Stephen McCarty et al. (2016, p. 361) suggest an ontology for a medical journey. The ontology consists of three main sections: the patient persona, the medical timeline, and the medical pathway. The medical pathway includes Encounters, which includes Tasks, which again includes Goals, Constraints, and Actors. Additionally, on the Encounters level, the structure of the journey map further includes the Emotional Journey, the Physical Journey, and the Device Touch Points.

Despite the fact that it is constructed from the point of view of the healthcare provider, the elements of the suggested ontology are very similar and also valid from the patient’s point of view. For the ontology of the international patient journey map, the following three elements are excluded: Constraints, Actors, and the Emotional Journey. Currently, there is too little knowledge about the emotional journey as well as the Constraints for a medical tourist. Further, the element Constraints in the context of McCarty et al. mainly focused on the constraints of the healthcare provider and not of the patient. The element Actors is excluded because the developed map in this paper will focus mainly on one actor, which is the patient.

The following suggested elements are included in the ontology of the map describing the journey of an international patient.

The patient persona will be described for a common understanding of the type of person that is considered and defined for this study. However, this might be separate from the patient journey map illustration for the sake of having a clearer overview. The persona will be described in a generic format outlining the main characteristics of the referred-to international patient.

The medical timeline is divided into three sections: Pre-treatment, treatment, post-treatment. This is in line with existing patient journeys (Hwang, Lee & Kang, 2018, p.7; Reljic, 2016, p. 4; Philpot et al., 2009, p. 467) which all emphasize the importance of recognizing that the journey starts already before receiving treatment and further continues after the treatment has been finalized. To portion the journey in more detail, the segmentation suggested by Heuser and Nagarajan (2018, p. 11) is overlaid, to divide the journey into Awareness, Search, Select, Experience, and Retain. Being the most generic but still detailed segmentation of a customer or patient journey, it will serve as the main structuring element to divide the journey into separate phases.

The medical pathway elements that Stephen McCartey et al. (2016, p. 361) suggest, are applied in a slightly adjusted manner for the journey map of this study. The Encounters, in this study called Interactions, are limited to the elements Tasks and Goals, whereas the Tasks are combined with the Interactions due to their congruent nature. In the ontology, the element will be labeled “Interactions related to medical tourism”.

For the element Goals, a separate section is dedicated. This element is given special attention because achieving the goal of the patient in every phase of the journey significantly influences the customer experience and satisfaction.

The physical journey is of particular importance for the model of this study due to the geographic distance between the patient and the clinic over the longest part of the journey. The element will therefore be applied in the ontology for the international patient map of this study.

Also, the element Device Touch Points will be integrated, again due to the geographic remoteness of the two interacting parties. However, the element will only be looked at from the point of view of the patient. To make it more appropriate to the investigated case, this element will be generalized to describe the interaction type and is labeled as such in the ontology.

Patient persona

The medical pathway elements that Stephen McCartey et al. (2016, p. 361) suggest are applied in a slightly adjusted manner for the journey map of this study. The Encounters, in this study called Interactions, are limited to the elements Tasks and Goals, whereas the Tasks are combined with the Interactions due to their congruent nature. In the ontology, the element will be labeled “Interactions related to medical tourism”.

The medical tourist’s home country is less developed with regard to the healthcare system. Certain infrastructure, medication, and treatments are not locally available, or if they are, not according to the newest standards. The international patient persona seeks care abroad to be treated according to the most advanced healthcare methods.

For referred to international patients, it is important to receive state-of-the-art medical treatment. To receive best care, the patient is willing to pay a much higher price abroad and invest much more time than receiving care in his home country. Further, the patient recognizes the advantages and disadvantages of a medical tourism agent and determines to select the medical facility him- or herself without a middleman coordinating the journey.

Mapping the journey of an international patient

In this section, the patient journey phases Awareness, Search, Select, Experience, and Retain are analyzed and described as to the medical timeline, the patient’s goals, the physical journey, the interaction types, and the interactions themselves.

Awareness

From a chronological perspective, the Awareness stage captures the time prior to a patient entering the active search process for medical facilities outside of the home country. At this point in time, the patient is in a passive role. Touchpoints between the healthcare service provider and the patient are therefore unstructured and coincidental.

These coincidental interactions could take place on a wide range of occasions. Due to the geographic distance between the patient and the healthcare provider, physical encounters can be assumed to be rare, possibly only during a visit to the medical tourism destination country. Other interaction occasions may include stories and experiences shared by friends and relatives that plan or already have traveled abroad for medical reasons, incidental encounters through digital channels, or marketing presence of the healthcare provider at the home country of the patient.

The importance of experience from individuals in the surroundings of the patient has been confirmed by Crooks et al. (2010, p. 9). Other studies have even found that the influence from friends and family is the most important information source for medical tourists’ decisions. This therefore equally applies to the Search and Select stages of the international patient journey. (Musa, Thirumoorthi & Doshi, 2012, p. 530)

The healthcare provider’s marketing can increase the Awareness of patients about clinics abroad and has also been recognized by Relji (2016, p. 4) from Swiss Health, an organization that formed part of Switzerland Tourism to promote medical tourism in Switzerland.

Search

The Search stage starts when the patient becomes active for the first time. The patient requires treatment and considers receiving this outside of his home country. At this point in time, the patient is still in his country of residence and therefore researches remotely for healthcare providers abroad. Available options include direct interactions with the digital channels of healthcare facilities, including search engine searches, social media channels, and other. Further to that, the patient might contact medical tourism agents or people he knows who themselves have previously taken advantage of medical tourism, thus visited a foreign country for medical purposes.

This is also reflected in the study of Bagga, Vishnoi, Jain, and Sharma (2020, p. 4449), who examined the main sources of information for medical tourists. They found that medical tourism agents, medical tourism blogs, and social media websites are the main sources of information. Crooks et al. (2010, p. 9) confirm these findings and further add promotional materials and information from friends and family, which was mentioned earlier already.

Hwang et al. (2018, p.7) also point out that in the pre-experience phase, patients search for information, in particular also related to reputation. Reputation from the patient’s perspective can be looked at in two different ways: Either the overall reputation of healthcare facilities, or in respect to the reputation of a clinic in the treatment of the condition. The latter would refer to clinics that have specialized in a specific medical field.

Further search criteria may include research for general information about the condition of the patient and state-of-the-art treatment methods.

Select

In the Select stage of the international patient journey, the patient needs to assess and compare the findings from the previous Search phase, eventually leading him or her to decide for one healthcare provider that meets the expectations and scheduling an appointment. The end of this stage has been reached once the patient has completed the transfer from his home country to the medical facility, and with that enters the Experience stage.

The necessity of assessing the different options to make a decision is supported by Crooks et al. (2010, p. 9). Crooks et al. point out the difficulties that patients face in their evaluation of possible options based on the insights gathered in the Search phase, which is due to a lack of international regulations and benchmarks.

International health insurance companies can serve as a benchmark for comparing healthcare facilities. These insurance companies maintain a global network of clinics and hospitals that are monitored in their quality of care and recommended to patients. Therefore, selecting a clinic abroad for treatment includes investigating if a clinic is part of the network of one’s health insurance company and if the facility is recommended by them (Heuser and Nagarajan, 2018, p. 11).

The interactions at the Select stage include booking a hospitalization package and scheduling an appointment (Philpot et al., 2009, p. 467; Relji, 2016, p. 4).

Prior to the experience at the clinic, Philpot et al. (2009, p. 467) point out the importance of the communication that takes place in preparation for the treatment. This is also confirmed by the findings of Hwang et al. (2014, p. 7).

Further to that, Voorheesa et al. (2017, p. 277) also recognize the importance of prior patients’ feedback for patients to decide for a healthcare provider.

Experience

The Experience stage includes the hospitalization stay at the selected healthcare facility, including treatment and post-treatment rehabilitation.

The patient journey map from Philpot et al. (2009, p. 467) examines this stage in further detail and suggests that interactions start with the check-in, proceed with the appointment, and end with the checkout. The same interactions can be applied in the journey map for international patients. Care interactions are further supported by Hwang et al. (2018, p. 5). These interactions include the treatment itself, and the interactions with doctors and nurses. Furthermore, related to the checkout, Hwang et al. (2014, p. 5) recognize the cost of the hospitalization. Linked with the cost is also the element of health insurance. Medical tourists that have appropriate health insurance want to make sure that the healthcare facility is being paid directly by the insurance company instead of paying upfront and claiming back the money from the insurer following that.

In the case of hospitalization, further elements must be considered: The patient receives an allocated room and requires provisions from the medical facility during hospitalization.

Reljic (2016, p. 4), in his model also takes up the importance for medical tourists to have access to wellness and rehabilitation treatments after the primary treatment. This especially applies to medical tourists seeking care outside their home country, not to benefit from lower cost but to take advantage of advanced infrastructure and treatments. Before leaving the treating facility and thus closing the experience phase, the findings of Yildiz and Mahmud Khan (2019, p. 471) indicate that planning for follow-up treatments is another element that must be considered following the Experience phase.

Retain / Enjoy

After completion of the treatment, usually a phase of further recovery and leisure follows before a medical tourist returns to his home country. The wording of this patient journey phase “Retain” originates from the point of view of the healthcare provider (Heuser and Nagarajan, 2018, p. 11). The patient, on the other hand, has no retention intention or goal following treatment, and the term therefore does not describe the phase from the point of view of the patient with sufficient accuracy. Based on this paper’s findings, this phase of the journey of an international patient will be renamed “Enjoy”.

In the post-experience phase, Hwang et al. (2018, p. 5) indicate that previous stages lead to feedback and recommendation. This can be applied to the journey map of this investigation as one more touchpoint between the patient and the healthcare provider.

Several sources have confirmed medical tourists after the treatment visit tourist attractions in the region around the medical facility (Reljic, 2016, p. 4; Hwang et al., 2018, p. 8; Yildiz and Mahmud Khan, 2019, p. 472). Due to its importance, it is considered another element in the interactions related to medical tourism and therefore complements the developed journey map and influences the overall patient experience and satisfaction.

 

5.     Result

The journey of an international patient significantly differs from the patient journey of a national patient. The geographic distance is one main factor that makes the journey of an international patient more complex, longer, and adds further tasks and interactions for the medical tourist compared to someone who seeks care locally.

Based on the findings from the analysis section of this paper, the author developed a patient journey ontology that is tailored to the specific situation of a medical tourist. The structure is an overlay of the traditional journey map phases, a medical timeline, the goals of a patient in every phase, the physical patient journey, interaction type, and finally the mapped interactions related to medical tourism in every journey phase.

The analysis further yields the input to the structural ontology along the chronological sequence of journey phases. The author proposes the following international patient journey map.

6.     Discussion and limitations

This paper and the developed international patient journey map significantly contribute to research as well as to business related to the medical tourism industry. Existing literature offers various insights and maps for understanding the patient journey. However, only very little is known about the journey of an international patient.

Further to that, most existing literature looks at the patient journey from the healthcare provider’s perspective. However, the researcher suggests that a patient journey map should be looking at the different phases from the point of view of the patient to be able to elevate the patient experience and satisfaction. The goals of and interactions between the patient and the healthcare provider may be overlapping in the Experience phase, but interactions are widely different in the Awareness, Search, Select, and Enjoy phase. An understanding of the interactions that are not directly with the medical facility is required to better understand the behavior and goals of medical tourists.

The developed ontology for an international patient journey map captures key elements that have not yet been captured by existing literature and proposed models. This includes mapping the physical journey, the interaction type, and interactions related to medical tourism in further detail. Future research may consider adding the emotional journey to the ontology to indicate in which emotional state the patient finds himself during the different journey phases. One can assume that this is strongly linked with the overall patient experience and satisfaction.

To further complete the understanding of an international patient’s journey that wants to benefit from more advanced treatments abroad, more empirical data from international patients must be collected and analyzed. Mapping the interactions between the healthcare provider and the patient in further detail will allow better understanding of the pain points in the journey of a medical tourist and help find ways to remove them, consequently improving the overall patient experience and satisfaction.

Further research will also help to differentiate the journey of a medical tourist that aims to benefit from the lower cost in more detail, compared to medical tourists who travel to high-cost healthcare locations that offer state-of-the-art treatment. This study contributes a first insight into this differentiation in the Experience phase. However, these findings may be complemented in future studies.

 

7.     Outlook

Crooks et al. (2010, p. 11) importantly points out that “Patients interested in medical tourism are also likely to hold responsibility for evaluating the trustworthiness and reliability of information sources (e.g., promotional materials, facilitators/brokers, friends and family) […] international regulation of the medical tourism industry is lacking, and so patients are left to their own – possibly with the assistance of others – to rate and rank things such as the quality of facilities and procedure outcomes using available information.”

Individuals seeking medical assistance and treatment are confronted with a massive range of clinics that claim to offer the best service for international patients. However, a lack of existing benchmarks for objective and professional comparison makes it difficult for patients to select the medical facility that best suits their needs, desires, and healthcare quality expectations. To further increase the satisfaction of international patients, the author of this paper proposes to develop an objective assessment framework for rating medical facilities. Widely applied, an assessment framework can be developed into a benchmark that evaluates and compares clinics’ value propositions for international patients on a standardized basis. With that, easier comparison and selection of clinics for international patients will be reached, and potentially the overall value proposition of clinics towards medical tourists can be elevated.

 

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