Texting for Health (Part 2) 11/11/11

Last week I wrote a post with some background on texting for health and listed some current applications. One of the companies I profiled, Voxiva, has received a lot of attention because of the text4baby program it manages. That program is being studied to determine its outcomes and return on investment. I’m curious to see how the effectiveness of text4baby is evaluated and how the findings influence text messaging applications in health.

The ability of text4baby to improve health outcomes should be evaluated. It doesn’t just reduce missed appointments. I’d categorize text4baby as a generic, passive text messaging health service. It is tailored to an expectant mom’s pregnancy stage, delivering weekly advice and educational messages about what is happening with mom and baby, hypothetically engaging and helping moms make informed decisions.

My opinion is that these messages are not tailored enough to be relevant to the majority of patients. Pregnant patients are generally motivated and engaged. Providing them with generic education and fun facts over SMS is nice, but I’m not sure it delivers much in the way of better pregnancy or perinatal outcomes. Maybe Johnson & Johnson is fine with this and is more than happy to fund this for the resulting PR, but HHS should not be funding it in the face of very limited resources for public health programs.

Back to generic messaging. With text messaging for health, and especially with chronic disease patients in which the goal is to help them make better decisions about healthy behaviors (eating, sleeping, activity, taking meds), some degree of individualized content with individualized guidance is necessary. Interactive text messaging (data to and data from the patient) and timely customer feedback are also necessary to keep patients engaged.

On that front, several companies, health systems, and payers are testing text messaging with individualized and interactive content. Other than text4baby and Text2Quit (smoking cessation) Voxiva offers a diabetes self-care messaging program called Care4Life (we get the naming theme.) This program is a part of one of the Beacon Grants, I believe in Louisiana.

While I question the return on investment for text4baby, I do like the idea of using SMS to improve treatment and medication adherence, though this too is not without challenges. Research is required to understand what does and doesn’t work.

To that end, a recent study of glaucoma patients found that a personalized adherence service from MEMOTEXT resulted in a 16% increase in medication adherence rates. Also, Denver Health recently completed the first stage of a trial using SMS messages to 1) remind patients to test their blood sugar, and 2) collect blood sugar readings via SMS response. Microsoft was a partner and its press release doesn’t talk about SMS, but that was the basis of the trial and their response rates were good at just below 70%. This is impressive, especially considering the age and socioeconomic status of the population.

The first challenge with using SMS alone for chronic disease and behavior change, as I’ve been told by user experience people, is that it is static. It offers no way to give a patient always-on health status or pre- and post-message insights. People get a message to take a med or eat a veggie or weigh themselves, then maybe a response saying "Great Job," and then they are disconnected again. This is not a great way to continually engage people in their health, something I think is necessary for behavior change.

The next major challenge is message fatigue. SMS campaigns need to be well designed to minimize the chance of message fatigue. If a patient takes six meds — some once and some twice a day — and is also supposed to test his or her glucose levels, then that’s just way too many messages to reach 100% compliance. For the time being, I won’t even address problem of lack of pill images in SMS when it is being used for medication adherence.

To achieve success, patient treatment plans, meds, self monitoring, activity, and diet need to be closely examined for each patient to determine the highest risk aspects of the plan. For non-adherent patients, decisions need to be made about which aspects would result in catastrophic health events and how to target them. This isn’t terribly easy to do, but getting it partly right is still better than hedging and sending reminders for everything so that users eventually start ignoring them.

Another aspect of texting for health is the interactive nature of some programs. WellDoc is great example. Patients submit glucose readings through an app (although there’s no reason this couldn’t be done with SMS) and WellDoc uses an algorithm to instantly respond with clinical guidance (eat something, take some insulin – I’m guessing they are more specific than this, or I at least hope so.) The patient is motivated to send the glucose reading because they get individualized, timely guidance.

Future Outlook

What will the future hold for SMS in health? To confirm where things might be going, you could look at the recent winners of McKesson Mobilizing for Health Research Studies. Several of the winners are using text messaging to improve data collection from patients as well as improve appointment attendance. Nothing really revolutionary, which just indicates a need for research of the current pilot areas where SMS is being applied.

I feel strongly that SMS is an essential component of any mobile health strategy. As such, it will increasingly be used as a way to communicate personally with patients. Certainly not all of the growing number of smart phone users will download apps from their payer, provider, and pharmacy (maybe all three of these will become one someday and the integrated model will rule, though I doubt it) so organizations will have to use SMS or maybe IVR to reach them on their mobile devices. They could use e-mail, but SMS and e-mail serve different purposes in my view.

HIPAA and privacy concerns are not going away. One approach companies such as mobileStorm are taking is to use SMS to distribute links to secure mobile sites and apps. This additional step, while not optimal, may be the key to linking SMS and PHI. Additionally, new, non-SMS messaging services like TigerText are using the familiar format of SMS, but securing it. These services still require apps, which limit the value of this for patient messaging.

In the short term, I think medication and appointment reminders, which both have a clear benefit if implemented correctly, will dominate. Though they aren’t very flashy, these will be the biggest short-term uses of SMS in healthcare. Applications of SMS in health, like text4baby, will eventually have results of their pilot projects published, and those will drive the widespread use of messaging services in the future.


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


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