While the potential for smartphone apps is still great, adoption across all mobile phone users in the US for apps has remained flat at about 10 percent for the past three years. Once these apps find tighter integration with hospital IT systems, more clinician champions, fine-tuned behavior change tactics, a clearer FDA regulatory framework, and (in some cases) companion peripheral medical devices, they will likely become more of a mainstay.
For years now, text message-based initiatives have seemed to be eating health apps' lunch.
[MobiHealthNews is hosting a webinar focused on Texting in Healthcare this Thursday, December 13th at 2PM ET. Be sure to sign up for your complimentary registration right here! We'll cover both provider-to-patient and provider-to-provider secure messaging, too.]
In an interview with MobiHealthNews in 2009, Partners HealthCare's Center for Connected Health Director Dr. Joe Kvedar explained why his team had focused on text message programs instead of apps: "We have been very fond of text messaging because it enables us to reach the broadest number of users. If you start out having to narrow your sample size because you are treating people with a certain illness or a certain level of engagement with the system already, then demanding that they have a specific phone or carrier, that can really, really dull the impact of your intervention," he said. "We have been more excited about text messaging and have used it as a reminder tool for the most part."
In 2009 PriceWaterhouseCoopers published results from its Consumer Access Survey that found about 21 percent were willing to receive healthcare information via text messages as an alternative way to access health information. Back then, some 55 percent of those surveyed said they were unlikely to use text messaging for health messages. While that many consumers were willing, a Microsoft survey conducted by Kelton Research around the same time (mid 2009) found that about 10 percent of consumers believed text messaging was the best way to receive health information from their insurer.
While the potential for SMS-based health programs has been a ripe one for years, adoption today -- surprisingly -- is actually about the same for both health apps and health-related text messaging services.
The most recent data from Pew found that while 80 percent of adult mobile phone owners in the US use text messaging, only about 9 percent used text messaging to receive health or medical information. Adoption was strongest among women, African Americans, and those between the ages of 30 and 49 years of age, according to Pew.
Over the years MobiHealthNews has tracked a number of patient- and consumer-facing text message-based health initiatives and trends. Below is the beginnings of a comprehensive roundup for SMS in healthcare.
Perhaps more than any other text messaging service that healthcare providers offer their patients, appointment reminders are the most widely available. In late 2009 Kaiser Permanente rolled out its text message appointment reminder service for its patients. The integrated health systems launched the service following a pilot study that determined the reminders reduced costs and made it easier for patients to make it to office appointments. The system, which was developed by MobileStorm, also included treatment reminders and lab result alerts. While KP may have helped to put the SMS-powered appointment reminder opportunity on the map, such services have been around since the early days of text messaging. Companies like Smile Reminder, which was founded around 2000, now serve tens of millions of patients appointment reminders.
Lab Results Available
While the specific results from labs should not be sent via regular old SMS because of privacy concerns, the fact that lab results are in is another low hanging fruit for text-enabled health services. Often a physician's office will text a patient to call in when a lab result has come in. In 2009 Massachusetts General Hospital (MGH) said it was developing an ATM-like kiosk for health, sort of like what Healthspot offers now, that performs a variety of diagnostic tests and then texts the patient their results later.
Prescription Refills, Ready for Pickup
An Accenture survey that was announced at the AHIP conference this year found that most patients surveyed (73 percent) would rather use their mobile phone to request prescription refills. Retail pharmacies have been quick to offer such services, too. In 2010 Walgreens launched its Prescription Text Alerts service, which lets customers know when medications are ready for pickup or if there are any status changes to the prescription. Rite Aid has also offered text, email and phone alerts for its Rx Reminders service for years now. Pharmacies use services like SMS-enabled prescription refills to help bring down abandonment rates for prescriptions, which currently hover around 25 percent for first fill prescriptions.
Weight Loss, Nutrition, Exercising
In 2011 researchers at the University of Michigan published a study that found tailored text messages could help teens adopt healthier lifestyle changes. Four focus groups consisting of 24 male and female teens in weight management programs were sent six different message types: testimonials, meal and recipe ideas, targeted tips, reflective questions, feedback questions and tailored messages. The teens responded well to instructional messages from peers, including recipes and testimonials about weight-loss strategies. Positive messages were also well-received, including exclamations and emoticons, but colloquialisms like “LOL” were not.
Earlier this year Pennsylvania-based health insurance provider Highmark offered up a text message-based health service, called Encouraging Words of Wisdom, for its members who are enrolled in its personal nutrition coaching program. The free program has individuals meet with a registered dietician up to seven times per year and the SMS component aims to help users stay motivated. The messages are not personalized for the individual members.
More recently Rock Health alum Sessions has been offering a text message-powered coaching platform that aims to help people stay motivated to exercise whether by going to the gym, exercising at home, or just walking regularly. The program includes texts from a coach throughout the week to check compliance with a workout schedule that the user and coach agree upon at the start of each week.
Food Allergy Alerts
In early 2010 Ireland’s national Food Safety Authority launched an email and text messaging service that aimed to inform food allergy sufferers about foods that have not appropriately labeled their products for the presence of common allergens. Once the authority establishes that a food product is missing the allergy information, the alerts go out to those consumers who subscribe to the service via the authority’s website — the agency also notifies enforcement officers and the offending food businesses.
In February the Centers for Medicaid and Medicare (CMS) announced plans to leverage the Text4Baby SMS-based initiative to increase enrollment in Medicaid and the Children’s Health Insurance Program (CHIP). Text4Baby participants will receive texts and information about pregnancy and infant care, along with texts about no-cost health insurance coverage available via Medicaid and CHIP. Specifically, the new texts included an InsureKidsNow phone number and website for users to visit to sign up for coverage. About 184,000 current Text4baby users were expected to receive the new messages.
Text message powered services that help people quit smoking have been among the most popular behavior change efforts in recent years. A meta-study of efficacy studies over the years found that, based on five studies, with a total of more than 9,000 participants, smokers who used mobile messaging interventions were twice as likely to make it six months without smoking than those who didn’t. There are a number of smoking cessation programs available in the market today that leveraged SMS. In September 2011 The U.S. Department of Health and Human Services (HHS) announced the launch of new SMS smoking cessation programs, QuitNowTXT and SmokeFreeTXT, as part of its Text4Health initiative. The programs, a collaboration with the National Cancer Institute, are aimed separately at adults, and teens/young adults, respectively. Around the same time Alere announced that it had inked an exclusive deal with Voxiva, which powers Text4Baby, for its smoking cessation program, Text2Quit.
Disaster Response, Emergency Alerts and Tips
Text messaging has been leveraged for disaster response around the globe in almost every recent major natural disaster. For example, following the earthquake in Haiti in 2010 the Red Cross sent public health text message tips to help Haitians in areas affected by a cholera outbreak to treat their symptoms. The service also instructed those in areas not yet hit by cholera to take preventative measures. The US government has recognized the critical role that text messages play in such instances so much so that it has created an SMS toolkit for disaster response, which it made available in June 2011. In 2009 the Centers for Disease Control and Prevention began a pilot that leverages text messaging to send information about the H1N1 (swine flu) and other health topics. The pilot is a three month long study that will also include feedback surveys from users to help the CDC better use the platform moving forward.
Mental Health, Especially for Teens
In 2009 a crisis telephone helpline for people with mental health problems in Surrey, UK began allowing callers to send text messages instead: While the functionality is intended for people who are deaf or hard of hearing, anyone who prefers to text may. The user can text a brief message that indicates the nature of the crisis and receive response via text, too. In 2009 Kaiser Permanente touted a text message-powered service, called Happy Factor, which is had no hand in developing, that helped users track their moods and general happiness by answering quick surveys over text. That same year a Robert Wood Johnson Foundation funded startup, called Living Profiles, mined the text messages of teenage boys and girls who had chronic diseases to passively determine their mental state. The group tracked and categorized the words that the teens used and then gave them updates that help the teens understand changes in their moods month-over-month.
Pregnancy and Maternal Health
Of course, some of the most high profile SMS-enabled public health campaigns from recent years have focused on healthy pregnancies and maternal health. In February 2012 then White House CTO Aneesh Chopra announced the launch of Text4Baby, a free mHealth service that “provides timely and expert health information through SMS text messages to pregnant women and new moms through their babies’ first year.” Later that year, the Washington Post reported on the launch of a similar service in Ghana developed in partnership with mobile operator Grameen: “In the past two months, Grameen has registered 500 expectant parents in the Kassena-Nankana area of Ghana, near the border with Burkina Faso, to receive free, regular phone calls and text messages guiding them through pregnancy. At week seven in the pregnancy, a parent receives a text reminder to take a malaria vaccination. At week 37, the parent is told that contrary to myth, eating fruits such as mango and proteins such as eggs is nutritious and won’t harm the fetus.” Not all pregnancy related text programs are for moms -- mobile health company Rip Road offers a text message-based service for expectant fathers called Duty Calls.
In 2002 the medical journal BMJ published a small study that found daily text message reminders helps people with asthma better manage their condition. From the abstract summary: "We set up a mobile phone text message service consisting of daily reminders to use an inhaler, health education tips, and safety messages. We streamed these into a supply of lifestyle related text messages about sport, celebrity gossip, and horoscopes; they were all written in contemporary text jargon and sent by a 'virtual friend with asthma' called Max. Thirty two young people with asthma from Tayside, Scotland, were recruited through local radio to take part in a study to assess the safety, reliability, acceptability, and effectiveness of the service." An even smaller 2011 study of seven children found that text message reminders did not help them better manage their condition. There are a number of SMS-based services for asthma available today. For example, Asthma Signals, a health program from Quvium, leverages text messages to alert families when the air contains certain asthma triggers in their area.
In recent years public health groups have recognized that the convenience and privacy of text messaging makes it a good channel for getting the word out about sexually transmitted diseases. In 2010 The Minnesota Family Planning and STD Hotline announced plans to improve its website begin providing updated services including Web chat and text messaging, in addition to its toll-free hot line. The group provides confidential health education and by offering personalized text messaging and Web chat options, users are now able to access information in the format that is most convenient. In 2009 The New York Times published a feature on a service in North Carolina called the Birds and the Bees Text Line, which is not automated, but staffed by nine professional texters with public health backgrounds. According to the report, many epidemiologists and public health experts believe sex education in the classroom is either ineffective or insufficient.
In 2010 endocrinologist and future entrepreneur Dr. Jennifer Shine Dyer made headlines for leveraging text messages to better engage some of her Type 1 patients. Dyer found that her weekly, customized text messages to remind adolescent diabetes patients about their personal treatment activities increased overall treatment adherence and improved blood glucose levels. In May 2011 Aetna launched an SMS-powered diabetes management service for members with help from partner Silverlink Communications in 2011. Washington, DC-based Medicaid managed care organization, D.C. Chartered Health Plan, announced plans to roll out a pilot text messaging program for members with diabetes earlier this year. Arogya World, a US-based non-profit, announced a collaboration with Nokia at the 2011 Clinton Global Initiative (CGI) Annual Meeting on an SMS-based diabetes prevention program in India. CareSpeak Communications announced a deal with UnitedHealth Group in 2011 to bring the health plan’s members two-way mobile text messaging services focused on improving adherence to treatment regimens.
The prospect of helping women remember to take birth control via text message reminders got a bad rap in 2010 when a high profile study found that such reminders did not change adherence to a birth control regimen. The study tracked adherence based on when a pillbox was opened — not self reports. The patients in the study, however, were aware that their pill boxes had the tracking device installed. In the control group women were encouraged to use their own tricks to remember to take their pill, and these included taking it as the same time as a vitamin or using their mobile phone alarm, which may explain why reminders via text didn't improve adherence rates -- the control group also likely had devised similar reminders on their own.
In 2009 The Red Cross announced that it would begin offering real-time alerts about critical blood inventories and tips for successful blood donations through text messages. Users opt-in to the program and can then choose to give blood when and where it is needed. The text even includes a click to call feature that allows the user to book an appointment right away.
Wait times at doctor's office, emergency room
Earlier this year several walk-in clinics in Montreal, Canada started sparing patients endless waits by sending a text or an automated voice message when it’s almost their turn to see the doctor. The problem of long waiting times is particularly acute in the Montreal area, where, according to local reports, 300,000 people do not have a regular family physician. In 2010 Boston’s MetroWest Medical Center launched a texting program that enables people to find out emergency room wait times. In 2010 The Wall Street Journal reported on the launch of MedWaitTime in Chicago -- a Web and mobile service that aims to help patients determine if their doctor is running late for an appointment. An orthopedic surgeon, launched the service with 10 Chicago-area doctors.
Text messages can also help people recovering from alcoholism. For example, one of the many SMS services provided by HealthCrowd is an intervention for recovering alcoholics that involves texting a person’s friends to remind them to congratulate him on a “sobriety birthday.”
In some developing countries knowing whether the medication you have purchased is fake or not is a rampant problem. Since the adoption of mobile phones has ramped up, a number of companies now offer SMS-based drug authentication services in those markets. One such company is Sproxil. In August Sproxil signed a deal with Indian telecommunications company Bharti Airtel for the latter to offer its subscribers in 17 African countries free texting for drug verification. Sproxil’s Mobile Product Authentication service includes a scratch-off label affixed to drug packaging. Consumers scratch off the label to reveal a unique code when they buy a medication or pick up a prescription, then text the code to a Sproxil SMS short code. A return text message reports whether the drug is real or counterfeit.
When it comes to successfully completing clinical studies, keeping patients enrolled is crucial. Lengthy trials pose a significant risk of patients dropping out, especially if invasive procedures are involved. In studies that include add-on trials, every patient’s continued participation grows even more valuable. In addition, making sure patients stay on course with all study requirements adds to this burden. While the need for effective retention and compliance measures is clear, they must be targeted to do the job. That’s where mobile technologies, especially text message can play an effective role. Many companies are now looking at ways to leverage texting and other mobile technologies to improve clinical trials.
Don't forget the sun screen
One of the earliest studies that Kvedar's group at the Center for Connected Health did that used text message reminders to put on sun screen. Kvedar is, after all, a dermatologist. "We did one study that was exciting where we compared a group of individuals who didn’t get daily reminders with a group that did. The goal of the intervention was to remind people to put on sun screen... We had a device that we could use that could measure whether people were actually putting sun screen on or not. Both groups had that same device. Every time they opened the tube to put on sun screen, it was a measured event that we could track. The intervention group had a daily text message that shared with them a weather report and reminded them to use their sun screen. That group had twice the level of adherence to the care plan as the control group. It was quite dramatic and statistically significant."
What are other patient-facing use cases for text messaging in healthcare?