Sometimes, a smartphone app is more than you need. Sometimes, it is not enough. Perhaps, the "just right" approach is simple technology like a text message.

That is the underlying principle behind CareWire, which automates appointment reminders and other administrative information so health systems can cut down on no-shows and unprepared patients in hopes of producing more productive encounters, reducing hospital admissions and boosting patient encounters. CareWire is the product of Minneapolis-based Healthy Heartland Inc. (HHI), one of the 10 startups that new health incubator Healthbox is supporting.

Each company gets $50,000 in seed funding and is participating in a three-month program in which they are given office space in Healthbox's temporary Chicago headquarters, plus access to a team of mentors. At the end of the three months, companies will make pitches to venture capitalists in hopes of scoring larger investments.

Healthbox announced its first class of startups in December began the mentoring program in early January. The incubator held a kickoff event and open house in Chicago last week.

"The genesis of CareWire is that there is a variety of ways currently to listen for patient satisfaction and patient dissatisfaction," Chief Operating Officer and co-founder David Nichols told MobiHealthNews in an interview during the open house. Those ways could include surveys, social media scanning or "ethnographic" interviews, according to Nichols.

"But we were thinking, what would be the least-cost, most widely available medium for engaging with patients and actually getting more or less a blink response from them as to their level of engagement, level of satisfaction, and so on?"

"SMS is nice in that there is no app to download and install. There's no specific password or security routine you have to go through," Nichols explained. Plus, most mobile phones made in the last 10 years are capable of handling SMS.

"At least currently, it's one of the most immediate messaging mediums out there. It has the brevity and directness of Twitter but it has the impact of instant messaging," said Nichols, who met business partner and CareWire CEO Scott Danielson when both worked at UnitedHealth Group.

At United, Nichols led the development of a business called UnitedHealth at Home, which provides short-term, post-discharge insurance for in-home care. Danielson later moved to AARP, where he helped launch AARPHealth, a health engagement portal for the organization and its members.

They founded Healthy Heartland in late 2009, and started working on CareWire in early 2011, developing the business model and getting feedback from providers, two of which became the company's pilot sites. CareWire now is testing its technology at Park Nicollet Clinics in the Minneapolis-St. Paul area and at Mercy Clinics in Des Moines, Iowa.

According to Nichols, the participating clinics have mobile numbers for 85 percent of their patients. One organization asks patients to opt in, while the other will include patients unless they opt out.

With Medicare cutting off reimbursements for some preventable hospital readmissions and with the advent of Accountable Care Organizations and bundled payments, health systems are finding less incentive to fill their beds and are more motivated to manage cases in primary care.

"In light of all of those things, innovative provider organizations understand that they need to create a lot more touch points with their patients than they did in the past. They don't have the resources to make all of those touches through traditional means like phone calls or letter writing," Nichols said.

During the pilot, CareWire is charging the clinics 15 cents per message sent and allow patients to respond for free. CareWire's value proposition is that there is no hardware to buy or install and that they can reduce no-shows, have better-informed patients, higher satisfaction rates and fewer preventable readmissions.

The two participating health systems right now are providing the company with scheduling and appointment information, so CareWire can send text reminders to patients and related information about how they need to prepare for an appointment, such as the fact that they have to fast or six hours prior to a physical.

"From the scheduling information, and configurations that we make to our system, we achieve three goals," Nichols explained. They get reminders of the time and location of their appointments; information on how to prepare for the visit; and, afterwards, a series of questions about the experience in order to measure patient satisfaction.

CareWire expects to interact with 10,000 patients by the time the Healthbox mentoring period ends in late March, Nichols said. The company will be collecting data on several metrics, in part to land VC investments and in part to show expected performance improvement to Park Nicollet and Mercy Clinics. Data really is at the heart of what CareWire is trying to accomplish.

"It occurred to us that, in order to create patient engagement and be able to drill into levels in of patient satisfaction and dissatisfaction, you had to go back to the data," Nichols explained. "Healthcare providers—doctors, clinics, hospitals—as we know, generate tremendous amounts of data through their EHRs and scheduling systems. That is really the source of truth in terms of where the patient is supposed to go, who they're supposed to see, what kind of appointment they're supposed to have, and unless you have that as context, then any kind of interaction that you have with them is meaningless," he continued.
"You can literally ask the million patients at a particular healthcare system how they happen to feel about the that healthcare system or how they happen to feel about the care they receive." But, said Nichols, unless you know those patients' preferences for which clinic they prefer to visit or what days of the week they prefer their appointments, the data is hard to make sense of. "It's all just one big average."

The patient experience is one reason why CareWire chose SMS over a smartphone app.

"It is about more than just what shows up on the screen of a device. It's basically the entire behavior that you're trying to engender in a patient or customer," Nichols said.

"[SMS] appears more crude or low-fi than a flashy mobile phone app, but when you pull the camera back and you think about the experience you're trying to engender, [the interaction] is made up of about seven messages, versus just a three-minute session on an app. You are basically trying to interact with somebody at various times and places in their healthcare experience," he explained.

"If you are prompted in the right time and in the right way, it's the overall couple of days before an encounter that you're trying to create an experience around, not just 3 minutes on a smartphone."