Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

THEROLEOFSMSMESSAGINGINIMPROVINGHEALTHCAREPROVISIONHealthcareCommunicationsLimitedJulieWacker05.01.2016

Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

OVERVIEWThisdocumentisdesignedtoprovideareviewoftheavailableliteratureastohowSMStext messaging can be used in communicating with healthcare users to improveHealthcareprovision.

IntroductionIthasbeentwodecadessincethefirstmobilephonetextmessagesweresentandinthattimetheirusageandpopularityhasexceededallexpectations.Today,textmessagingisthemostwidelyusedmobiledataservice.IntheUK,93%ofadultsownamobilephone(66%ofthemaresmartphones)andtheaverageUKresidentsends117SMSorMMSmessagespermonth,indeed15%ofadultsintheUKare‘Mobile-Only’homes(OfCom,2015).

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Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

ThePlaceforSMSinHealthcareProvisionTraditionally, healthcare providers have communicated with patients about theirappointmentsusingpostalservicesandlandlines.ButwhataretheoptionsforutilisingSMStoinnovateandimprovehealthcareoperations?

Q. Howdopatientsrespondtotextmessagingaspartoftheirhealthcareprovision?

Itisimperativetoexaminehowpatientsrespondtobeingcommunicatedwithviatheirmobilephonesabouttheirhealthcareprovision.Theresearchonthisisprettyclear;mostpeopleprefertobecommunicatedwithviatheirmobilephone.55%ofrespondentstoasurveybyOfComin2014saidthattheirmobilewastheirpreferredwaytobecontactedabouttheirappointment.Thisfalls inlinewiththegeneralbehaviouralpatternweseewithmobilephones,mostpeoplehavetheirmobilephonewiththematalltimesanduseit formanyvaried functionsoverandabovephonecalls, suchascalendars,emailandphotographs.

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Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

AgeandDemographicsThereismuchanecdotalevidencethatcertaindemographicgroupsarelessreceptivetobeingcommunicatedtobySMS,howevertheresearchdoesnotappeartobackthisup.A study by Hughes and Done, 2011, titled ‘Not 2 Old 2 TXT’ examined this apparentphenomenon and found that older adults actually did not necessarily object to SMScontentforpatientandappointmentinformationmorethananyotherdemographicand44%werewillingtoreceivetheirappointmentreminderbySMS.However,thisstudy isfouryearsoldandsincethenmobilephoneownership inthoseaged 65+ has increased significantly and according toOfCom figures in 2014, 42% ofpeopleintheaged65+agegroupnowhavemobilephones,andsoitwouldmakesensethat the findings of another studywere alsomore pertinent now. Finkelstein and Liu(2013)foundthatageandotherdemographicvariablesdidnotpredictresponsivenesstoreminder systems, and instead it was the familiarity with the service provider thatpredictedresponsivenessandeffectivenessoftextmessages.Ifpeopleknow,trustandareengagedwiththeprovider,theywillusuallyrespondpositively.MostpeopletrusttheNHSintheUK,sothereforethisstudyisespeciallyinteresting–itmaybetruethatpeopleofanydemographicwillmostlikelynotobjecttobeingcontactedbytextfromanNHSproviderbecausetheyareseenasatrustedorganisation.

These findings back up theexperience of HealthcareCommunications in sendingover 100 million SMSmessages to a variety ofpatient demographics; it isdifficulttocategorisepatientsby demographic andwhethertheywillrespondtoSMS,andolder aged patients mustcertainlynotbeautomaticallydeemedasunableorunwillingtousetexttechnology.

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Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

OtherDemographicConsiderationsAnimportantconsiderationinchoosingamethodofcontactisalsothesocio-economicstatusofthehealthcareuser.26%oftheDEsocioeconomicgroup(WorkingClass/Non-Working)and27%of16-24saremobile-onlyhouseholds.This statistic is important becausemobile is often now themost effective channel ofcommunication to these groups because evenwhen addresses change, the easewithwhichpeoplecannowretaintheirmobilenumbersoftenmeansthatmobilenumbersareretainedover longperiodsof time,andessentiallymobilephonenumbers remain theonlyconstantcommunicationpointforthesegroups.

AreviewofalltheliteratureontextmessageremindersinhealthcareservicesbyKannistoetal,2014,foundthatofthe70studiestheyreviewed,‘textmessagereminderswereeasytouse,usefulforpatientsandpeoplewerewillingtoreceivethem’.Forallofthesereasons, it is importanttobreakdownsomeoftheapparentstigmainusingSMSasaformofcommunicationbythehealthcareproviders,especiallytoolderagedadults.

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Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

WhereisSMSanEffectiveCommunicationToolinaHealthcareSetting?AppointmentreminderstoreduceDNArates

MissedhospitalappointmentsareamajorsourceofinefficiencyandmanyhealthcareprovidersnowuseSMSTextmessagestoreduce‘DidNotAttend’(DNA)rates.Numerousstudies and reviewshave systemically shown that sending reminders via SMS reduceDNArateswhencomparedtoNoReminderandPostalreminders(Gurol-Urgancietal,2013). One of the most commonly cited reasons for missing an appointment is‘forgetting’ and the SMS reminders serve to eliminate this major reason for NotAttendinginaproactiveandefficientmanner.Dependingonmobiledatacapturerates,usingSMSasareminderservicecansignificantlyreducetheDNA.

Inthestudy,patientsweresentadailySMSorIVMtoratetheirpainlevelsandifthepainwasratedhighlythenanursecontactedthepatientandadaptedthetreatment.Theuseof IVM/SMS proved to be a reliable assessment of pain intensity and even in theseterminallyillpatients,allweresatisfiedwiththeintervention.This studyproves thatso longas the intervention iswell-designedand functional, themode of communicating via SMS and IVM can be a feasible and acceptable way toimproveresponsivenessandtheexperienceofthepatient.

Post-dischargeSurveying

A study in 2015 by Kees et al,showedaninnovativeuseofbothSMS and IVR (Interactive VoiceMessages) in theassessmentandmanagementofpain.

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MedicationReminderServices

PooradherencetotakingmedicationfollowingdischargeisawidespreadproblemintheNHS,causingrelapsesinconditionsatratesthatarehigherthandesired.SMShasbeentestedasameanstoresolvethisissueandtheresultshavebeenpromising.Bogartetal,2014,foundthatautomaticSMS reminders forantipsychoticmedication ‘Wereacceptable to themajority ofsurveyrespondents,regardlessoftheirdemographicanddiagnosticcharacteristics,attitudestowardsmedicationandlevelsofpastadherence.Theprospectofaflexible,minimallyinvasive,cost-effective and broadly applicable tool that can potentially improve adherence toantipsychotictreatmentisexciting’.

These results are especially interesting because they were undertaken in aMental Healthenvironment,whereanecdotallythereisareluctancetouse‘newer’technologiesbecauseoftheperceivedorrealvulnerabilitiesofthepatientsandananticipatedinvasivenessofanSMSmessage.However,itseemstobethecasethatthetechnologiesmaywellassistinimprovingoverall care to the patients and the patients most often respond well to this form ofcommunication.Itseems,usedwiththought,SMScanassistinimprovingcarepost-inpatientdischarge,eveninaMentalHealthsetting.

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Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

TheFutureContentofMessages

Asalreadyestablished,SMSremindershavebeenshowntobeeffectiveinreducingDNArateshoweverattentionisnowshiftingtotheminutiaeofthecontentofthemessaging.Usinginitiativesfrombehaviouralpsychology,itisnowemergingthatthewordingofSMSreminders significantly affect the extent to which patients miss, attend or canceloutpatientappointments (Hallsworthetal,2015).Specifically tested isamessagethatstates the cost of the appointment should the patientmiss it, and using this specificcontent,DNAratescanbereducedbyaroundaquarterinrelativeterms.

NB.TheSpecificCostsmessagereceivedthelowestDNArateinthestudybyHallsworthetal,2015.Theimplicationsofthisemergingresearchhasclearfoundationsforfuturepolicieswithinpatientcommunication,howeveritisalsoclearfrombehaviouralpsychologythatthisisnotsomethingthatwillstandstill.Theeffectofthemessageabove,forexample,willhavealimitedlifespanbeforeitisnormalisedandwhenthathappenstheeffectsarereduced.SothechallengefortheHealthcareProvidersistoconstantlyinnovatetheirmessagingtosustainthe‘nudge’.

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Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

CapturingMobilePhoneData

93%ofadultsintheUKhaveamobilephone.IftheNHSwereabletocaptureallthisdata,thepossibilities for reducing costsand increasingefficienciesbyusingSMSmessagingwouldbeclearlymaximised.MostTrustshave inexcessof40%ofmobilephonedatacapture rates, however the challenge for Trusts is how they efficiently increase thecaptureof thisdataand integrate this formof communication into the cultureof theTrust.ManyTrustsrelyoneitherthereferralrouteorreceptioniststocapturethedata,butitisclear that those with the best mobile number coverage have implemented moreinnovative initiatives and processes to actually capture the data, such as having anenforcedpromptsonthecontactdetailscreen.

SUMMARYSMS as a technology has been introduced gradually into our communications withinHealthcareprovision,andasweculturallyacceptthelegitimacyofusingSMS,wewillseethatthepotentialforusingitcanoffercostbenefits,serviceimprovementsandincreasesin patient satisfaction. It is a reliable technology with a far reach within the patientcommunity, andwhen usedwith integrity can deliver a wide variety of benefits in ahealthcaresetting.

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Healthcare Communications UK Ltd, Stewart House, Royal Court, Macclesfield, SK11 7AE. www.healthcare-communications.co.uk

ABOUT US We'releadersinpatientcommunicationssoftwarewithsystemsliveinmorethan1000NHSsitesincludingTrusts,DentalandGPPractices.OurplatformisdesignedexclusivelyfortheNHSwithdirectinputfromthefrontlinestaffusingit.Findoutmoreathttp://www.healthcare-communications.comContactusatjwacker@healthcomm.ukTel:08459000890

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REFERENCESBesse,K.T.C.,Faber-teBoveldt,N.D.,Janssen,G.H.P.,Vernooij-Dassen,M.,Vissers,K.C.P.andEngels,Y.(2015),PainAssessmentwithShortMessageServiceandInteractiveVoiceResponseinOutpatientswithCancerandPain:AFeasibilityStudy.PainPractice.doi:10.1111/papr.12278BogartK,WongSK,LewisC,etal.Mobilephonetextmessageremindersofantipsychoticmedication:isittimeandwhoshouldreceivethem?Across-sectionaltrust-widesurveyofpsychiatricinpatients.BMCPsychiatry.2014;14:15.doi:10.1186/1471-244X-14-15.CarJ,Gurol-UrganciI,deJonghT,Vodopivec-JamsekV,AtunR.Mobilephonemessagingreminders for attendance at healthcare appointments. Cochrane Database Syst Rev2012;7:CD007458.Hallsworth M, Berry D, Sanders M, Sallis A, King D, et al. (2015) Correction: StatingAppointmentCostsinSMSRemindersReducesMissedHospitalAppointments:Findingsfrom Two Randomised Controlled Trials. PLoS ONE 10(10): e0141461. doi:10.1371/journal.pone.0141461Hughes,L.D.,Done,D.J.&Young,A.1Dec2011.Not 2 old 2 TXT: There is potential to use email and SMS text message healthcarereminders for rheumatology patients up to 65 years old, Health InformaticsJournal.17,4,p.266-27611p.KannistoKA,KoivunenMH,VälimäkiMAUse of Mobile Phone Text Message Reminders in Health Care Services: A NarrativeLiteratureReviewJMedInternetRes2014;16(10):e222Stacey R Finkelstein, Nan Liu, Beena Jani, David Rosenthal, Lusine Poghosyan, 2013,AppointmentReminderSystemsandPatientPreferences:PatientTechnologyUsageandFamiliarity with Other Service Providers as Predictive Variables, Health Informatics,Volume19,Issue2,p79-90.http://media.ofcom.org.uk/facts/

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