Texting for Health – Part 1 (11/4/11)

Digital messaging in healthcare is more complex and more expensive than in other industries because of privacy and security requirements, with hefty penalties for those found to be in violation. HIPAA requirements around protected health information (PHI) limit the communication mediums and content that organizations (payers, providers, pharmacies, business associates, etc.) can or are willing to use.

For this series of posts, I’m going to focus on the current use and future potential of text messaging (SMS) for healthcare communications between providers and patients.

Background on SMS in Health

SMS is ubiquitous, even here in the US, which has lagged behind much of the rest of the world in adoption of the technology. Some recent reports have speculated about the future growth of SMS, which I’m sure does not make carriers happy, and I think there is a real threat to traditional SMS from new services like iMessage from Apple and other short message services like Twitter and Facebook. Still, short messaging services will continue in one form or another.

CTIA data shows that the average number of text messages per user per month is over 500, though I’m sure that number is a bit skewed by the younger contingent. Another survey by the Pew Research Center found that 72% of US adults use SMS. The rest of the report is worth reading if you’re interested in how the US population is using mobile phone technology.


Some Current SMS Applications in Health

SMS for health is nothing new. Heck, there’s a book on Amazon on this one topic. My first exposures to SMS for health came when I was exploring international opportunities to utilize SMS to improve healthcare delivery. As is the case with SMS use generally, health-related services in developing countries utilize SMS much more than we do in the US, empowering remote health workers, pharmacies, health promoters, administrators, and increasingly patients with health-related notifications.

In the US and Europe, SMS is intriguing as a form of communication with patients, but I think the threat associated with lack of security limits its applications. Despite the lack of widespread adoption in the US, HHS has a text4health Task Force that is examining successful applications of SMS and ways to both scale current efforts as well as expand into other areas of health.

With SMS being such a dominant method of communication, what is being done to use it to reach out to patients (remember all that patient-centered language in the proposed ACO rules and reform talk) and hopefully improve care? One service is appointment reminders. This obviously seems less risky than sending an SMS with somebody’s STI test results.

The NHS in the UK has been using SMS for years to notify patients of upcoming appointments. The NHS claims improvement in missed appointments, so there is an obvious return on investment for this type of service, which really should not cost much to implement. WHO agrees that SMS appointment reminders are great, finding the NHS to be the most advanced mHealth nation in a recent report on the subject.

US providers are increasingly turning to SMS for appointment reminders as well, though Kaiser still calls me with automated messages the day before appointments, which drives me crazy. Speaking of calling vs. texting, does anybody listen to voice mail anymore? I had a conversation with somebody recently about the death of voice mail. I let Google transcribe my voice mail, then text it to me. The transcriptions are not perfect, but I get the gist of the call, which always seems to be enough.


Back to current SMS application for health in the US. One of the programs cited as a shining example of success in this area is text4baby, which sends timely messages to pregnant women with advice and educational content. text4baby, developed by Voxiva, is bankrolled by the government and Johnson & Johnson, and has won several awards.

Not everyone is a big fan of text4baby. I was asked recently by a CIO why he’d pay to build a mobile pregnancy tool, like text4baby, when his pregnant patients are far from the biggest problem, in terms of cost and outcomes, for his organization. I don’t really have a response to that because I find it hard to believe that sending a weekly SMS about eating right or not smoking or drinking really improves pregnancy outcomes. Maybe I’m wrong, but I haven’t seen data that says so.

Either way, not only are efforts underway to ramp up enrollment in text4baby, but Voxiva has launched several other SMS-related health services. The first, Text2Quit, helps smokers quit. Again, I’m just not sure text messages are going to help people quit smoking. One study often cited for using SMS in smoking cessation concluded, "The research showed that text messaging is at least as effective as more expensive and harder-to-use handheld data collection devices in the ‘brief interval assessment’ of people in smoking cessation programs". Again, I guess we’ll have to wait and see the results.

There are lots of other interesting applications of SMS in healthcare that all parties (payers, providers, pharmacies) are testing out. I’ll cover more next week and also highlight what I think are major limitations of SMS for health, especially as it related to patient behaviors.


Travis Good is an MD/MBA involved with health IT startups.

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