February 26, 2018 | Sherry Dillon, RN, CPHRM
Patients are just 160 characters away
It’s 12:15 p.m. on a Monday. So far today I’ve received six text messages from different people. Three messages from my children, an appointment reminder from my dentist, a flash sale for my favorite nutritional supplement, and a package delivery confirmation from Amazon. I responded in every instance, either by sending a reply or taking an action:
- Kids. “Congratulations on rocking your science test!” Followed by a heart emoji.
- Kids. “Yep, we’ll be home later. Dad will be able to check out the car noises in your car.”
- Kids. “I’m sorry we won’t be able to babysit on Friday night, weekend getaway planned.”
- Dentist. Replied “yes” to confirm the appointment.
- Sale. Replied “no” to the sale (I’m already stocked up).
- Amazon. I opened the door and retrieved the package.
My 100 percent response rate is typical for Short Message Service (SMS) messages, also known as text messages. In each case, it took less than ten seconds to respond.
The converse is true when it comes to voicemail—I have two that I still haven’t listened to. When a call to my sister to confirm if she’s coming for a visit this weekend turns into a 45-minute conversation, I wish I would have just sent a text message. Turns out, there are a lot of people just like me. People prefer text messages over phone calls or emails for brief communications and short interaction.
- 98 percent of the United States population responds to the text messages they receive.
- 97 percent of Americans use text messaging at least once a day.
- Six billion texts messages are sent daily in the United States.
- Approximately eight trillion text messages were sent globally in 2017.
With the ubiquity of SMS technology in 2018, why aren’t more healthcare organizations utilizing text messages to engage their patients in the post-discharge stage? Speaking with multiple healthcare industry leaders has helped shed some light on why they’ve resisted the shift to other forms of communication. Bravado Health set out to find out why they’re hesitant to change, and offered some concepts and solutions to the challenges of engaging the modern patient.
Two-thirds of homeless people have a mobile phone
During our interviews with healthcare leaders, we heard that socioeconomic status and, more specifically, homelessness are perceived barries to engaging a patient with mobile technology. Not surprisingly, this segement of the patient population tends to be the most difficult to engage in their own healthcare recovery overall. “Many homeless people simply do not have this capability,” was the line from most hospital executives. Statistics say otherwise.
A recent experiment was conducted in a city with one of the highest homeless populations in the United States: San Francisco. In 2015, there were 7,539 homeless inidivuals in the district. Of 7,539 people living on the streets of San Francisco, 3,384 had a phone with the capability to send and receive text messages. That’s approximately 67 percent of the homeless population that had a phone which could text.
The experiment didn’t stop at the numerical data. It went further to determine whether utilizing texting technology to engage this population would be viable. Not only did the data support the assumption that the “homeless population are becoming more and more equipped with mobile phones and SMS technology”, but that they felt more supported by their community and less alone. The article highlighted one homeless person, Kerry, who responded as if he had made a new friend—sharing jokes, stories, and experiences.
While we strive to acheive 100 percent inclusion, 67 percent is certainly a great start—and a lot better than zero. That’s at least two of every three homeless indivduals that could benefit from text messages connecting them to a primary care physician, community resources, ridesharing, shelter availability, and other programs.
Elderly people text more often than you think
Another common response from healthcare leaders was that they felt most of their higher risk patients, such as those with one or more chronic conditions, were often elderly and typically don’t engage with newer technology.
According to recent studies, however:
- People ages 45-65 are the fastest growing demographic on mobile devices
- 50 percent of adults age 55 and over own a smartphone
- 94 percent of smartphone users 70 years and older text on a weekly basis
- 82 percent of smartphone owners over the age of 65 prefer texting as opposed to phone calls or emails
Text messages can be HIPAA-compliant
Some of the stakeholders we spoke with had concerns with text messages related to patient confidentiality and Protected Healthcare Information (PHI). Institutions have faced stiff monetary penalties under the Health Insurance Portability and Accountability Act (HIPAA) for breaches of patient confidentiality. They asked us, “How can a text message be protected?”
First and foremost, obtaining informed consent and the right mobile phone number are integral. This information needs to be accurately recorded during the initial patient visit and updated at a minimum annually per HIPAA guidelines. Informed consent, must include verbiage of not only who can receive patient information on behalf of the patient, but also how the patient can receive it. Whether receiving consent to leave a voice message, send a letter, email, or a text message, there must be written approval by the patient or guardian in advance. Because mobile numbers can change periodically, it’s a good practice to reverify the mobile contact number with every visit.
Second, a HIPAA-compliant text messaging provider will help ensure that the organization is doing everything possible to ensure the security of patient information. Be aware that not every SMS provider is HIPAA-compliant.
Third, establish board-approved criteria, policy and procedures regarding the types of information allowed to be transmitted via text messages. Highly sensitive personal information such as records of sexually transmitted diseases (STDs), or Acquired Immune Deficiency Syndrome (AIDS) diagnoses should not be referenced within a text message. Unencrypted links, lab results, and other vital information should not be included.
Measure the impact of texting
Analyzing text message interactions not only helps measure difficult-to-track behavior such as medication adherence and discharge instruction comprehension, it provides insights into high-risk patients and how to engage each segment of the population more effectively. We spoke with a hospital executive who recently implemented text messaging to engage their patients. They were using a clinical professional full-time resource to engage patients with follow-up calls. After implementing text messaging, their follow-up call volume went from thousands a month, to less than 20 a month. Now they focus on only the highest risk patients who are not engaged.
Find a company that will share texting statistics with you. Read rate, clicks and “STOP” responses all provide valuable insight into recipient behavior. Understanding the rationale for patient opt-outs will help improve your messaging strategy. Start correlating texting data with demographic information such as age, gender, and nationality to determine which groups are most receptive to text messaging. Outcome measures, such as revisits in the ED or readmissions into the inpatient setting, should also be trended.
It’s time for healthcare to catch up with the 21st century
While the world is becoming more connected, digitalized and globalalized—healthcare is struggling to keep-up. Electronic Health Records (EHRs) have been around for decades. Legislation requiring the implementation and use of EHRs has also been around for years. Yet, technological challenges such as information exchange, documentation, and interoperability still prevail.
Most of the healthcare community’s skepticism regarding texting patients revolves around lack of awareness of the prevalance of mobile technology, and misconceptions about information security. Armed with the right information, healthcare leaders should be excited to embrace the potential for such opportunities to engage their patients directly after they leave their facility.
Perhaps a favorite quote by one of the most famous historical figures in nursing says it all:
“It irritates me to be told how things have always been done. I defy the tyranny of precedent. I cannot afford the luxury of a closed mind.”
We want to hear from you
Do you utilize texting technology as a way to engage patients? If so, how have you utilized it? How has it affected your patients or practice?
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