Is there hope for SMS health alerts?

Richard Fury, MD, of Kaiser Permanente emailed me recently, asking: “Is there any hope for SMS health alerts when patients are due for preventive care?  As you know, patients want this, we want to provide this, but without symptomatic incentives adoption is poor. Thoughts?”

I think there is hope for SMS health alerts targeting people under the age of 65 (and particularly those under 50). Look at the potential market:

Pew Internet: Demographics of  cell- and smartphone ownership, Sept 2012

Pew Internet: Demographics of texting, Sept 2012

However, just 9% of cell phone owners say they receive any text updates or alerts about health or medical issues. (See: Pew Internet: Mobile; Mobile Health 2012).

For more evidence, I recommend following the work being done at the Center for Connected HealthText4Baby, and txt2stop. I’m also interested in the SMS emergency alert systems set up by local, state, and federal governments — maybe they’ll prove the market for health alerts.

What other evidence would you recommend, either pro or con? Have there been failed attempts at SMS health reminders? Successes I didn’t name? Please post in the comments.

65 thoughts on “Is there hope for SMS health alerts?

  1. When I talked to my Online Consumer Health students during the H1N1 pandemic about the use of SMS for health messaging, they laughed because they received so many H1N1 messages and warnings that they ignored them. Context and volume are important issues! So is wording – during a water main break affecting most of Greater Boston, considerable effort was put into clear, concise, unambiguous, and action-oriented messaging.

    I am currently engaged in a research project to pilot the use of 2-way SMS with diabetes patients in India. I mention this because I am looking for data like the above about texting (I know the use of cell phones is very high in India but indications are that SMS is used for news, jokes, astrology, and similar purposes). I am also looking for studies about 2-way SMS ideally with diabetes patients in India, but additionally for any disease in any part of the word, since most initiatives, like the ones Susannah mentions, are 1-way. I am happy to report back as this progresses, and hope Susannah forgives me for my request for information.

    • Hi Lisa,

      You are exactly right, most methods, or at least in the past has been 1-way. The ultimate goal is interaction and what stimulates users to act?

      I’m not sure how you are currently using the communication whether its automated or live person, but automation and triggers can be pre-established and programmed for workflow and follow up processes.

      Would love to learn more how your program progresses.

  2. I remembered hearing about a txt-based public health outreach program for Bedouin women, so I searched for it today and found this article: Jordanian Health Program Connects Bedouin Mothers With MDs via Text | Fast Company – http://vsb.li/JvHBfo Outgoing messages were voice recordings, so as to empower illiterate recipients. I don’t know if this particular program has survived (the article is a year or so old).

  3. I wasn’t doing this research for you, Susannah, but for my project. From WHO http://www.who.int/pmnch/events/2010/2010_pf_innovation_sms/en/:

    An interactive, web-based sexual health platform (Love Airways) and a condom manufacturer (DMK), in Indonesia joined hands to offer a choice of different methods through which young people can access information. One of them is the short message service (SMS Sex Education) on mobile phones. Young people send questions and receive responses as short messages from “Dr Love” – which are timely and helpful. A database of 20 000 questions have been keyed in to generate responses from an “Avatar” – an artificially intelligent virtual character. This ensures privacy and confidentiality.

    • Goodness, I never dreamed that you were doing this research on my behalf. I’m just happy to provide data that sparks conversation and contributes to a better understanding of the impact of tech on health. Thanks, as always, for sharing what you’re working on.

  4. Great article and well researched! This is a fascinating topic and I love the SMS alert products, like Text4Baby and txt4health.

    Given the other comments, I am wondering if there is any future in 2 way automated texting services? We produce a triage expert system and we have wondered if it would make sense to create a triage bot accessible via SMS. The upshot would be: “you text us a symptom and we guide you to care.” The goal of triage is not to diagnose, but to provide the user with a call to action: WHEN to seek care and WHERE you should seek care (ER, UC, doctor office, retail clinic, etc.). Are you aware of any companies that may be interested in exploring this with us? Perhaps this idea is nuts? : )

    • Hi Dr. Schueler,

      You are not nuts. We do exactly what you are referring to with thoughtful personalized logic. I’m happy to explore this further with you and show you some real-time examples that I’m confident will create some synergy.

      Looking forward,
      Ron O’Ferrall – ron@urlocus.com
      Head of Mobile Engagement
      urLocus, Inc

  5. Thanks for posting Susannah. As someone who developed a very basic system for outgoing health messaging years ago then moved to a research career in understanding mobile interventions, the hope seems to lie in how we tailor the messages for the population and condition (as is suggested above) and how we integrate multiple triggers and techniques within the message to engage and motivate individuals to act. Prevention is never as pressing as illness and we need to use the literature on how lower short-term importance goals are facilitated. Is there a link to a 2 minute instructional video or is a joke for younger kids. As mentioned above by Stefan– two way automated messaging is happening but is needed to be connected to a higher level of intervention intensity or peer social networking for non-responses. How we create social accountability with in the our interventions as David Mohr writes about can be applied to SMS as well which is certainly fun. Also – one thing we have realized with elderly and messaging – is that they are receptive but not to overwhelm with too many messages or ecological assessment that requires different responses for different messages! Keep it simple for sure with this population. Thanks again for opening the discussion and for these interesting comments (and for Jeremy for alerting me to this post). I have made many mistakes in developing these programs but see wonderful promise for sure and looking forward to all the new research which will surely be coming out in the next few years.

    • There’s so much I want to follow up on in this comment – thanks, Fred! How do we create social accountability within interventions? How to deal with non-response? So key. Like Nikolai Kirienko’s observation that no status update from a chronically ill or medically fragile friend may, in fact, be the signal to get over to that person’s apartment ASAP.

      Also, I should have looked first to MobiHealthNews for a round-up piece on this topic. Luckily the health geek tribe on Twitter reminded me (thanks @mosio + @theRealDanSfera)

      Text messages: The workhorse of mobile health? by Brian Dolan
      http://mobihealthnews.com/19440/text-messages-the-workhorse-of-mobile-health/

        • Thanks, Jessica!

          Your organization is doing some neat stuff in this area. On Twitter, I read about this event on Feb. 14:
          http://ythlive.org/google-hangout/sms-text-messaging/

          “Are you using text messaging to reach youth? If 87% of youth sleep next to their mobile phone, turned on and more than 1/3 of all teens subscribe to text alert services—why wouldn’t you?

          Because it’s not that simple. Many public health and social justice organizations are using texting to reach youth and in the past few years we’ve seen a lot of what works and what doesn’t.”

          • Yes, ISIS is having a Google Hangout on mHealth for Youth and we hope to have the same level of energy around this topic as on your site!

            Save the Date: mHealth for Youth Google Hangout
            Feb 14 at 10AM PT/1PM ET with our Executive Director, Deb Levine, Paul Meyer of Voxiva, Tom Subak of Planned Parenthood, Eric Leven of RipRoad, and Sam McKelvie of Mobile Commons.

            Sign up here: http://ythlive.org/google-hangout/sms-text-messaging/
            It’s in preview of our conference in April. Hope to see you all there!

  6. This reminds me of a post by Roni Zeiger yesterday, regarding tapping into networks of microexperts – http://ronizeiger.com/networks-of-microexperts/

    He makes the argument that real progress will be made when questions beyond the specific expertise of a physician get bubbled up to a wider network of experts.

    Applying that thinking to SMS messaging – One of the primary ways many of these programs are managed is to automate responses to questions based on a database of answers. It strikes me that we are doing this backwards – that responses to specific health questions often require direct answers and follow-up. Why not route a single question not to a database, but to a network of professionals that can respond if they are able? First response gets through and establishes a connection for follow-up. There are examples of this in patient-to-patient, right?

    Are there examples of SMS programs that have sent SMS based health queries to a larger network of physicians and public health folks that could respond individually? Kind of like quora for health questions… but who wants to ask a question about an STD on quora?

    The privacy, immediacy, and personal nature of SMS is made for health and I think the two-way conversation is what makes it most effective. There’s a reason those notifications about the flu begin to fall on deaf ears – we know they are automated.

    • Awesome! I left an epic comment on Roni’s post – thanks for the tip.

      And “who wants to ask a question about an STD on quora?” is the quote of the day.

      • The question is really how do we reach the population we want to reach …. And the answer will be different for each condition, for each behavior change, for each demographic group. On the STD front, MTV ran a campaign a few years back where folks who were tested could get a badge on Foursquare. Perhaps not a badge I’d be vying for, but for the right demographic, it works …..

    • Great idea. A friend of mine created the first SMS Emergency Textline with the Dept. of Veteran’s Affairs which is similar to your idea. Veterans would text questions or statements to the system and a professional would then pick it up from there. Depending how the conversation went they would eventually call them when they felt comfortable.

      This has prevented countless suicides amongst our veterans but unfortunately currently not publicly promoted because the success was so overwhelming the VA feared being under staffed.

      Something similar can be done with, dare I say a call center of healthcare professionals intercepting SMS with filters that avoid abuse, but personalized because it is someone on the other end. I see your thought on using a network of medical professionals but really unless they are getting paid to answer that text, especially if its not their patient might prove a bit tough?

    • Wow, I am so enlightened by the microexperts article, thank you for sharing! In my opinion, 160 characters to communicate specific health problems in a 2 way SMS service doesn’t seem very practical, especially since patients express their problems in so many different ways. Perhaps a middle ground between 2 way and automated messaging is best.

      • Great point Jessica. We are testing a feature now that allows for more than 160 characters in SMS correspondence. With more smartphones on the rise, the inbound SMS beaks up 1/2, 2/2 at character 161 (depending if the word is whole or not)

        In addition, the ability for the interaction to be routed to a professional to pick up the conversation.

        The VA currently has a similar program in place for its Crisis hotline.

  7. Hi Susannah!

    There have been some great responses here, so thanks for the invite to the conversation. It’s great to see how SMS is picking up serious momentum right now, especially in the healthcare arena. Not surprising this is another industry brainstorming for relevant mobile solutions.

    In response to Dr. Fury’s direct question: Yes. There is hope for SMS health alerts in preventative care and there are many solutions for increasing adoption rates.
    As Dr. Fury referenced we already know patients want it and healthcare communities want to provide it, so the simple answer lies in thoughtful technical and functional integration, creative rollout, as well as staff training to encourage adoption.

    The low adoption rate of 9% isn’t necessarily lack of interest as much as it is lack of access to such services. More importantly, large organizations and agencies are finally (in the last 4-6 months) seeing SMS as the immediate and long-term dominant solution for mobile communication. Now that over 50% of users are 35+ (Nielsen 2012) it makes all the sense in the world. The problem is there aren’t many experts in this space because this type of communication is very different because its so personal. We don’t want commercials on our phone, we use it to communicate…so talk to us.

    Our approach matches the tone, theme and culture of the brand and customizing simple opt-in solutions for both office and patient. For example, a patient visits Dr. Fury and the front desk schedules the patient for preventative care or a follow up. The assistant schedules the patient for a month later 1/20/2012 at 1PM and encourages to be reminded via SMS (Being Kaiser, both English and Spanish options are offered). Upon confirmation the assistant verifies their information, checks a box and the patient’s mobile phone buzzes and asks them to reply “Y” to confirm their appointment with Dr. Fury.
    On 1/19/2012 at 1PM the patient’s phone buzzes to remind them of their scheduled appointment the following day with a number to call to reschedule if necessary. Another message can be sent an hour prior to their appointment as well. (We discourage a voice call message because many Americans do not answer calls they are not familiar with and rarely check voicemail in time)

    As we gather data we also implement logic to provide a more personal experience such as:
    Hi Susannah, just a reminder about your 12PM Appointment with Dr. Fury tomorrow. Reply “Y” to confirm or “R” to reschedule. (upon replying R you will be routed to the front desk.)
    Reply “Y” –
    “Thank you, see you soon. Our address is 123 Front St. STE 213, Anaheim, CA. For directions just tap: http://bit.ly/map or call us at: 305-555-1234.

    Of course from a smartphone upon tapping their navigation opens up to get them to the office and they can see the address, or call.

    Signage and compliance posters would also be displayed in the waiting area with information handouts so patients can opt-in (and be educated) prior to being seen. Based on a series of interaction, we refine interests and keywords to provide more specific conversational marketing and bilateral communication exchange in the future. Keeping in mind any solution would need to stay within MMA and HIPAA regulations to ensure proper authentication and privacy. Similar to how banks and other institutions currently use SMS authentication.

    As more data is gathered, the more diverse the applications such as Physical Therapy reminders, Dieticians can send food tips and reminders, Pre-op information reminders, during flu season patients can text FLU to get the closest location to their zipcode…no GPS required.

    This is just scratching the surface and currently available so please let Dr. Fury know we’d love to collaborate on solutions for the community!

    All the best,

    Ron O’Ferrall
    Head of Mobile Engagement
    urLocus, Inc
    @txtSFL

  8. Susannah – thank you for the shout-out!

    From our perspective, the biggest problem we all have to solve is how to connect with folks in a way that matters to them. Once you get a handle on that, every medium has a role, depending on what challenges you are tackling at that moment.

    We call it a “surround sound” approach — for us, that means using whatever medium we can in whatever way we can to help people be happier, healthier and more productive. Since most of our customers have phone numbers on members, and not much else, that often means using voice (automated, interactive phone calls) to engage people in an information-rich yet accessible way about their health, capturing that valuable opt-in for outreach in other mediums, then offering a hand-off to other programs (like an SMS-based one) that can support them in a different but very complimentary way.

    For example, we’ve partnered with Voxiva to deliver a coordinated phone and SMS-based diabetes management program. You can read more about that partnership and the program here: http://ow.ly/gelFa

    By bringing together these different types of touches, we can carefully monitor engagement and call to action rates across all mediums. After all, just because a member says they want to receive phone calls, for example, doesn’t mean that’s the most effective channel for the desired outcome.

    One last point — as many folks have suggested above, the topics that tend to lend themselves best to this kind of communication are the ones that address the problems real people want solved — questions about sex, or pregnancy, or other areas in which folks are already highly engaged and hungry for support. To Lisa’s point above, it’s not creating value if it’s just creating noise!

    Thanks everyone on this thread for sharing your insights and experiences.

    • Hi Susannah! Nice to see your post on this. And Eliza too.

      I think SMS has a huge future in clinical medicine if it can make sense of HIPAA, which has specifically excluded it, as I understand, as a secure medium for clinician-patient interaction.

      If it can’t, and I do not think it can, I think its future will be mediated in the private sector, and in the governmental sector, and the nonprofit sector. It could do even better.

      We’ve used it (as I think you may know) in our first beta test of Refuel! aka Manly Eating to offer gender-specific informational and action-oriented messages to individual men as a way to improve engagement and enhance adherence to the suggested eating program, meant to help men lose weight, fat, inches and gain strength.

      We found that well over half (63%) responded to at least 75% of our texts over a 24 day period: only one man had a response rate under 50%.

      You can read more about the beta test here: http://manlyeating.com

      So we think texting (with appropriate messaging) may also play an important role in helping overweight and obese men, who prefer not to be involved in group meetings or other conventional dietary processes, become lean, strong and fit.

      If this isn’t the public health dilemma of the early 21st century, I don’t know what is. We intend to ramp up the next beta to be national so we will look at voxiva and I hope other choices.

      Warmly
      JL

  9. You might find the following study of interest
    Diabetes Buddies : Peer Support Through a Mobile Phone Buddy System; The Diabetes Educator 2012 38: 357 Purpose
    The purpose of this study is to test the feasibility and
    acceptability of a mobile phone–based peer support
    intervention among women in resource-poor settings to
    self-manage their diabetes. Secondary goals were to
    evaluate the intervention’s effectiveness to motivate diabetes-
    related health choices.
    Methods
    Women with diabetes (n = 22) in Cape Town, South
    Africa, participated in a 12-week program focused on
    providing and applying knowledge of health routines to
    manage diabetes. Women were linked with a buddy via a
    mobile phone for support and were questioned daily
    about a health behavior via text message. Women were
    assessed at recruitment and then 3 and 6 months later by
    a trained interviewer using a mobile phone for data collection.
    The women were evaluated on technology
    uptake, reduction of body mass index, blood glucose
    levels, and increases in positive coping and general
    health-seeking behaviors.
    Results
    Women exchanged 16 739 text messages to buddies and
    received 3144 texts from the project. Women responded
    to 29% of texted questions (n = 1321/14 582). Women
    attended at least 9 of 12 possible intervention sessions; a
    third attended all 12 sessions (n = 8/22). Between baseline
    and 3 months, women increased their sleep and
    reported a higher level of positive action and social
    support coping, yet blood glucose increased by 3.3
    points. From 3 to 6 months, spiritual hope decreased and
    diastolic blood pressure increased. One year later, the 22
    women continue to attend meetings.
    Conclusions
    Mobile phones are an easy and reliable way to provide
    peer support and disseminate health messages. Both positive
    and negative changes were observed in this pilot study.

  10. Preliminary data from an ongoing Medic Mobile (http://medicmobile.org/) pilot in India showed a ~20% — absolute, not relative! — improvement in childhood vaccination rates by sending SMS messages to mothers. Of note, the SMS messages were automatically generated by a custom EMR system. Transparency alert: I’m on the Medic Mobile board of directors, and it’s a non-profit :)

    Like just about everything, it’s not the technology, it’s whether a real person’s problem is being solved in a way that works for them. Certainly room for SMS to be a part of this for a long time yet.

  11. Thank you all for the helpful comments. Text alerts sent to patients due for preventive care can be quite powerful (see Roni Zeiger’s post). Yet, active opt-in adoption has been difficult for populations. Will capturing opt-in by other mediums (as Eliza Corp has done) be necessary for SMS to help improve preventive care on a large scale?

    • Hi Richard,

      Yes it is. Cross-platform promotion is the key ingredient in building any permission-based database, especially a mobile database. If truly embracing SMS as an entry point for ongoing communication, the points of entry should be integrated and numerous.
      Some we’ve included in other campaigns are:
      - Texting in to a shortcode
      - Online forms
      - Station with iPad/ Tablet
      - Staff input via CRM (Custom add-on for easy entry)
      - Staff input via mobile phone (EzOptin, very effective)
      - Sign up sheets with SMS verification
      - The list goes on

      More importantly is the mobile creative (different than traditional marketing) and strategy in delivery so it matches the tone, theme and culture of the organization.

      Some Technical Considerations:
      Delivering large scale there are also technology considerations that must be thought through such as systems integration, throughput, bandwidth, IVR integration and other important factors.

      Some Functional Considerations:
      Sending a Flu shot reminder to 10 million people takes thought and consideration. I will tell you that would be a poor decision to send this blast at once because staff would be overwhelmed and product would run short, thus leaving an undesirable experience.

      However the ability to send SMS to 10 million people because of an emergency, epidemic, extreme weather, natural disaster or sending preventative health tips, that is a great time to reach them all as quickly as possible.

      I look forward to continuing this discussion as this is an area of strength for us. Sharing knowledge is power.

      Thank you,

      Ron O’Ferrall
      Head of Mobile Engagement
      urLocus, Inc – ron@urlocus.com

      • This is a really interesting discussion. Thank you everyone for such insightful comments!

        The tough part with permission based sms is where do you draw the line? For example, if a dentist purchases a CRM that enables staff to double opt in a mobile phone of a new patient, is it reasonable to assume that because they’re a patient, they want the sms alerts? Reality is, not everyone appreciates sms alerts from their dentist. A helpful widget in an app could make for very disgruntled patients. And, as this level of service becomes increasingly available, the end user will have to decide which media they want coming through their sms inbox. In a recent focus group we conducted with 18 to 25 year-olds in response to a question: would you subscribe to health alerts from you doctor? Or from a health dept? We were surprised by the responses. Most said maybe or no. In fact, several had done so before and opted out, stating that in the beginning content was relevant, however, messages became increasingly more general – so, they cancelled the alerts. As with all listservs, as they increase in size, content must become more generalized to resonate across all demographics. If you already have your listserv, then the ability to subgroup based on personal interests & demographic profile suddenly becomes a significant challenge. Especially when you consider the next generation of subscribers grew up texting with friends and family. They’ve grown accustomed to instantaneous, personal connections and nearly immediate responses each time they text, tweet or post. In the workplace and in their day-to-day interactions, they expect the same environment.

        In health alerts, there’s really two very distinct objectives. Building a listserv versus maintaining one. We’ve consulted with health departments that are afraid to send a message to their listserv because each time they do, regardless of the content of the message, it will inevitably trigger opt outs. So, before building a listserv, it’s always a good idea to know what you’re going to send them. And if you’re able to develop sub-groups within a listserv, based on triaged responses, then you’re well ahead of the vast majority of sms health alert programs. Ideally, you begin your alert program with your populations already sorted based on personal interests.

        Targeted, Individualized messaging should always be the primary concern in any sms alert program. The sms inbox is quickly becoming a highly coveted space. You must earn your spot there or be opted out.

        • Great points Jonathan.

          You probably already know this but the bottom line is SMS being permission-based is a requirement through the FCC and CTIA. Fines are as high as $1,500 per violation so purchasing lists or even a listserv are ill advised.

          In regards to your example of dental patients receiving regular SMS, that would also be ill advised. Seriously, who wants to receive an update form their Dentist? We barely want to see them because they yell at us let alone receive an update. But I see your point loud and clear.

          Conversational marketing has its place in just about every industry but healthcare. In this industry, trending topics, appointment reminders, periodic blasts with tips is about where it should be. Perhaps 1-2 messages per month.

          However if someone is opting in for example, Women’s Health, well that calls for more frequent engagement, usually weekly.

          I’d also like to add 18-25 year olds are a demographic that is less likely to use SMS health alerts in preventative reminders. The demographic in my opinion should target 25-65+ because these are who would most likely be in various healthcare facilities. Not to mention 35-55+ year olds makes up over 50% of SMS usage in the US.

          Subgrouping based on interests and demographics should always be at the forefront and we’ve had great success in this area and are currently consulting with a large national triage service. It’s much easier than you think, it’s all in the initial build and fully understanding the purpose that database has to the organization. Having populations already sorted would be a God send however that’s not the case unless a list is purchased, and then it’s just plain SPAM.

          Sending a blast to an existing and owned list (with explicit permission to send SMS) is a great entry point, however educating the audience on the purpose of opting in is imperative. Are they getting only appointment reminders? Quarterly flu shot reminders? Prescription reminders? Perhaps it’s a group that is interested in a weekly health tip. So long as you let people know they are fine with it.

          It’s all about taking the time to understand what each message means to each person. There is a life for SMS in healthcare so long as it is employed correctly and cost effectively.

  12. Thanks, everyone, for continuing to post ideas — and Richard for posting another great question. I think this is a thread we can continue to build and a great example of how a blog can gather resources through conversation. I’m so appreciative of everyone’s input!

  13. I don’t think that the marketing of the advantages of SMS communication has been done well enough with the patient and provider community. Think of the absolute millions we spend on health care marketing and yet when it comes to digital usage (texting certainly being one) the money spent is significantly less. To Dr Fury’s original comment, the answer is absolutely YES. However until we do a better job of explaining to the customer WHY they should be adopting and signing up for these things, adoption will continue at a snail’s pace. The ‘what is in it for me’ question has not been comprehensively answered for the customer by anyone. As someone said above, this isn’t a technology question. It is a value question.

  14. We’ve helped several hotlines and help lines launch two-way text programs for youth and young adults. In fact, a primary reason we developed the two-way platform was from lessons learned from one-way health alerts programs that we developed beginning in 2007. Most sms alert systems in public health use group wide messaging. So regardless of you geographic location, you’ll get the same messages everyone else gets. Just as one of your readers points out, people tend fatigue unless messages are tailored to their specific needs. Improving public health and safety for end users and service providers is a core principle of our work. We believe the best mobile health alerts programs utilize a combination of automated health alerts (based on triaged responses) with live two-way responses from trained staff when subscribers respond to alerts. SMS was developed for brief, two-way interactions between two entities. Fully automated health alert programs begin with the notion that exchanges will be one-way only. This we feel is a misstep when considering how most people utilize the medium.

    • I agree 100%, Jonathan. The more you can place a human touch it become more personable. We helped advise on that very thing with the VA for its Crisis Hotline using SMS. There were automated responses initially then a professional took over. It was an overall success however the drawback was hiring, training and managing the personnel to man the lines. This may not be true in all cases but until an organization fully embraces it as a viable resource, convincing them to burden a cost can be tricky. I think this year, 2013 will break a lot of barriers and we will see more of this type of interaction embraced in 2014

  15. Thank you for the invite Susannah!

    At ISIS, most of our projects target youth of specific demographics. A SMS project we are currently working on is called “Today is for Tomorrow” and targets middle-high school students in California. In addition to the text messaging, there will be a website and social components, specifically Tumblr at the moment. Here’s what it looks like now although we are still experimenting with it: http://todayis4tomorrow.tumblr.com/ Instead of personalized SMS messages, which has a character limit, we can engage youth using social media. It’s also a great way to reach youth where they are, which is on the internet. This project will be done in conjunction with San Francisco Unified School District and their health teachers.

    In addition to interaction/personalization, marketing and language have been pitfalls of SMS. Creating the right language to engage each audience is tricky, teenagers especially since they think they are invincible and are not interested in health at all! I found this study helpful: http://www.futurity.org/health-medicine/teens-say-okay-to-getting-health-info-in-texts/

    Anyway, I just love the discussion going on right now and hope you all can join us on February 14th for our Google Hangout on “mHealth for Youth” with Deb Levine, Paul Meyer, Tom Subak, Eric Leven, and Sam McKelvie! http://ythlive.org/google-hangout/sms-text-messaging/

    Best,
    Jessica
    Media & Communications Officier at ISIS
    ythlive.org

    • Hi Jessica,

      It’s great to see what you are doing with this project! I couldn’t agree with you more in the way SMS is presented. It is far different than any other marketing medium because it’s so personal.

      Kudos in keeping the social, mobile, digital integration in play. SMS is a great entry point and CTA, but the interaction goes much further than that especially when introducing rich media such as photos, videos and online spots to interact further.

      Mobile creative and CTA verbiage is certainly still evolving and great projects like this are lessons we can all learn positively from. I’ll definitely be following.

      Regards,
      Ron O’Ferrall
      Head of Mobile Engagement
      urLocus, Inc

  16. Great conversations and thread here. And my comments are a bit late to the game after promising Susannah I would add comments after my tweet from December holidays. But holidays and flu and work piled up. Alas, better late than never (scouts honor).

    First, on a macro level there are great things happening in “mhealth” just as there are in “quantifiedself”. I for one, hope that one day the field and reference to “mhealth” goes away and is sunsetted. It should be health broadly and holistically, regardless of setting, device, or location.

    In any event, I had expressed in my December tweet that privacy and regulation could hinder text based mobile health (mhealth) adoption and behavior change here in the US. I will explain my original thinking a bit further here but also have refined slightly my rationale after a few weeks of thought here and there to my original posit.

    PRIVACY: this is a barrier, and across two dimensions, provider and consumer although more friction I think towards the latter. For the provider impact, healthcare organizations are scared to death about HIPAA and PHI compliance in this growing age of technology and mobile integration into the healthcare delivery system. Hospital and provider group laptops with patient health information and records are lost and breached every week it seems, and we all are aware of the penalties for these PHI violations. In terms of collecting the mobile numbers for patients, this information clearly has to be volunteered by the patient in an opt-in manner. The PRIVACY impact for consumers is the friction here. Most people do not want to willingly provide their mobile phone information, for fear of constant bother no matter time or place. The mobile phone and regular calling and text exchanges between people are reserved for a smaller circle of people than everyone in your network or contact list. The number of people who have your cell phone number and whom you engage with regularly via talks and texts is certainly smaller than the e-mail contact list you have. It is a personal platform, that is walled off for many people and is like a Google circle in that regard. While some people would welcome and want that help from their HC provider and not feel it intrusive, I believe most (unfortunately) do not want that type of regular message fatigue. It remains useful, pointed, as impactful if only it is contextual to you, delivered at the right time, and individually messaged. I’m not certain we are there yet in terms of NPL or whether groups like ElizaCorp have found and perfected the secret sauce to allow such targeted text communications that will sustain interest over time vs fatigue.

    Now, there have certainly been examples where text based SMS programs have driven health and behavior change as cited here, although much of this has been ex-US or in lower income populations here in the US. I think another reason why this SMS model has succeeded for other populations in Africa, Latin America is that mobile phones period are life and economic currency there versus the US. They are an integral part of life, people are dependent upon them in Africa versus the luxury they are here in the US as it relates to use/consumption/interaction. In those countries because of MNO infrastructure being 1 or 2G versus 4G here in US or Europe, and because of per capita income differences, feature phones are utilized versus smartphones. Therefore from a mindshare perspective, they rely on the phone, for what it is – calls and texts. There aren’t tens of thousands of apps, videos, Web browsing to be done at all, and if so, not regularly because of network speed and capacity issues. Obviously this isn’t the case in the US. Your SMS text messages compete with Facebook, Twitter, Angry Birds, etc. So – people I think keep their cell phones to a smaller circle, don’t willingly offer it up, and SMS conversations are for friends and family predominantly. Not health or finances.

    REGULATION – my reference to this as a barrier was more along the lines of “true” healthcare behavior change, not the general fitness or diet or nutrition tips that are out there and predominate the 15,000+ health apps. The personalized and detailed stuff, like how was the infusion dose today or how is the cleaning and debriding of your foot ulcer going? Surely this type of meaningful and deeply personal communication, even if opted in by patients and conducted via SMS, needs to be regulated in some way. Whose responsible from a policy perspective, HHS, FCC? It is unclear whose domain it would fall to, but the need for security and privacy for these communications and archival of such (for treatment adherence, documentation, incorporation into EHRs and patient records) need to be outlined. It is unclear to me whether providers would want this responsibility in terms of data integrity and privacy adherence.

    Anyway – welcome thoughts and other POVs and data/reports to prove I’m off base or need to be aware of other developments.

    Susannah – sorry for the delay!

    @1CharlesH

    • No apology necessary! This thread proves the Ted Eytan maxim: The conversation is never over. I’m grateful to everyone for continuing to contribute.

  17. SMS is greatly undervalued. According to @RosinaSam Truth On Call’s statistics, it takes MDs an average of 8 secs to respond to SMS. There is no time to mess with apps without the same ease of use and speed.

  18. Thanks to a physician for letting me know this thread was going on. I know I’m late tot discussion but I’m the Founder and President of Truth On Call, an SMS based communication platform for physicians. Obviously I do believe there’s hope for SMS for patient, physician and the “interaction between the two” communications. SMS is much easier to access, respond to and does not require a smartphone, or as some users and apps, wifi. The first keystroke in response to an SMS is getting to the heart of what that person says. With an app there are at least 2 keystrokes (one to open the app, the second to click to answer) and often many more to get to a place where you’re actually responding to something. From an alert perspective SMS can’t be turned off, where app push alerts obviously can. Obviously the SMS service must comply with FCC regulations but the alert system is so much more reliable than in an app.

    I’d love to hear people’s thoughts and if you’d like to continue the conversation and follow up on any questions please don’t hesitate to reach out. I’m always eager to learn from physicians, techies and especially the two combined!

  19. Are healthcare providers avoiding the use of text messaging due to uncertainty regarding the HIPAA Security Rule and related FCC guidelines? http://is.gd/feucFI http://is.gd/LJXTBL

    If so, how much morbidity and mortality could be prevented by wide spread, yet reasonable use of text messaging for preventive health purposes?

    • There are several programs now providing two-way crisis support through sms. Youth-focused crisis texting services are now available through hotlines and helplines in 17 states. For example Boys Town recently launched a statewide campaign for Iowa Public Health Department, (www.yourlifeiowa.org) where Iowa teens can text a dedicated short code and get two-way feedback from a Boys Town counselor. Other state efforts in Minnesota, Nevada, and New Jersey have seen tremendous results when they launched texting support for their youth populations. And teenlineonline.org uses peer counselors to reach teens through sms.

      In an upcoming National WIC conference, they will be discussing their success with Peer Counselors and the efficacy of two-way texting to communicate with young moms on the go. This project uses breastfeeding awareness alerts (in English and Spanish) as a catalyst for two-way texting between participating moms and their Peer Counselor. So, the education is a valuable component… however, when moms have a specific question about a resource or breastfeeding tip the ability to reply to those messages and get live feedback has made that project a huge success and garnered attention from National WIC. Remarkably, the WIC Peer Support Texting program has enjoyed a 100% retention rate.

      And 211 centers in Oregon, Nevada, and Florida are now using two-way sms to connect families to resources like health care, child care, food, shelter… 211 is the 411 for community resources. Texting makes their services infinitely more accessible. And, as discussed in previous posts, research supports that people prefer to ask for help through text. In fact, anything that carries a stigma is more accessible through text.

      Programs that have long provided phone support (help lines, hotlines, information and referral services) are now finding the younger generations (who have grown up texting) are expecting services to also be available through two-way texting.

      Is there a place for sms in public health and safety? Most definitely. Texting is available on every phone, by every wireless carrier made, by every phone manufacturer, running every operating system. It’s everywhere. Text is the gold standard and no one is in any hurry to abandon it.

      The key is to correctly match your content with your target population. And with the capacity to support live interactions in agencies like WIC and 211, there’s a natural and synergistic relationship developing between National health goals (like addressing obesity in children and families) and the local agencies that are invested in bringing those messages to the community level. If the messages are delivered to large segments of the population and then those messages result in more families being connected to resources – and, moreover, text is the medium by which that is accomplished, then sms has an invaluable and sustainable role to play in the future of health care and preventive health services.

  20. Johnathan: Agreed, text messaging is available on every wireless phone regardless of its operating system and carrier. Also, I agree no one is in a hurry to abandon it. There are selected examples of success and research shows consumers want more. Yet, I remain skeptical about its role in public health and preventive services. SMS has been available for many years, but the healthcare footprint of this simple, inexpensive and ubiquitous technology is absolutely tiny. Why?

    • Dr. Fury. You’re right. While there are examples of successful projects, the footprint remains small. We’ve been pushing on this since 2006. In fact, we submitted for an NIMH RO1, and subsequent R21 in 2006 to provide mental health crisis texting support through a hotline. While the proposal was well reviewed, the director of NIMH grants (at that time) stated that they didn’t feel sms would be around for very long so they funded mental health themed video games instead. And it wasn’t until 2011, that HHS submitted recommendations through their Text Task Force http://www.hhs.gov/open/initiatives/mhealth/recommendations.html. We’re just now starting to see calls for texting in RFPs, but not nearly as frequently as we should. Historically, SMS health programs have been highly successful abroad. But texting became popular abroad much soon than it caught on here in the US. Typically, on the technology front, United States is on the leading edge, however, in the case of text, US has been slow to the table. For instance, in a lit review we conducted in ’06, we found numerous group-based health alert programs in Africa, Great Britain, Australia, New Zealand, S. Africa, Indonesia and several others. We also found examples of bidirectional mental health support programs in Britain and S. Africa. Whereas, in the US we found just a few examples of health alerts and absolutely no examples of bidirectional live support. Another factor to consider is sms’s primary audience (individuals who grew up texting) are just now reaching adulthood. And it’s this group that will be seeking healthcare services and products with the expectation that these services be accessible through sms channels. So, maybe, sms’s audience had to mature first and with the deployment of the Affordable Care Act, we’ll see that demand skyrocket. First with resource provisioning, linking folks to healthcare, and then with patient/provider interactions, once those folks have found their medical home.

    • Thanks for keeping this discussion going Richard. Reading the comments and most recently that of Jonathan’s last night, part of the issue has been care providers understanding of this ubiquitous communication. When I say “provider”, I don’t mean the corporations themselves but those in the trenches being the individual case managers, clinicians and doctors. Many of whom until their kids started using SMS did they start to see and understand the overwhelming utilization of this form of communication in people’s lives (over 2,200,000,000,000 SMS messages sent in the US in 2011). Yes, there are market maturity aspects but we are finding a dramatic demand push from patients to communicate this way, as this is how they communicate with everyone else. Our clients our coming to us saying that their patients are telling them they want to communicate with SMS and are scrambling for a solution. On the other hand, as we have discussed Richard, its not just a matter of using the technology but how its used. When the messaging/interactions are tuned to the individuals needs at that time, in a manner that makes the most sense, and is not in isolation but ties in their larger health eco-system, there are dramatic results. Fundamentally the issue is not just an available means of communication but an understanding of how to use the communication to create an effective dialogue that is valuable for the patient and the provider.

      So the short answer to your question is, with over 6 Billion SMS messages sent every day, the horses have left the barn on this. It has become a fundamental means of communication and due to its device/mobile provider ubiquity will continue to grow for the foreseeable future. BUT for successful use and engagement, it cant be just looked upon as a simple 160 characters pipeline for simple communication. In fact, because of this simplicity, the messaging content has to be crafted to provided information valuable for patient and provider. Its been this lack of attention to creating engaging content that can account for some of the limited uptake to date. That said, I think you’ll be surprised in seeing a major shift in the very near future.

  21. Childbirth Connection’s Listening to Mothers III report is out and includes these data points related to our discussion:

    27% signed up to receive short text messages, with 17% of all mothers using Text4baby

    See: Data Brief related to expectant mothers’ use of the internet

  22. Hi Team SMS,

    My Pew Research colleague and I just received a great question and would love to be able to answer it if anyone knows of a data source.

    Here we go:

    “I’m currently conducting research on the use of texting in post-disaster communication and was trying to find a specific statistic – the percentage of Americans who do not know how to text.

    Based on your 2011 Americans and text messaging report, I can see that 27% of Americans don’t send or receive texts…but that doesn’t necessarily mean they don’t know how to do so. I was wondering if you or any of your colleagues had recently posed the question of whether people know how to text in a survey?”

    Anyone?

  23. Mhealth Alliance (http://www.mhealthalliance.org/) recently reported that “sms is the single most important communication channel for reaching people regarding awareness and enrollment for the Affordable Care Act.” We are supporting 211 contact centers (and other “navigator” appointed community programs) with a simple solution that will route folks to their state’s marketplace website (if available) e.g. http://www.coveredca.com/ or to the healthcare.gov site for those states not yet supporting the reform efforts. Nearly 50% of Americans do not know the current status of the ACA. Basic info is needed and text has a critical role to play in both education and enrollment of the 1 in 5 that are uninsured and the millions that will need guidance in determining whether their current solution is the best option for their family. PreventionPaystext.com will support large-scale outreach as well as two-way conversations with live support for those requesting it. A leading platform for contact centers, helplines, hotlines, WICs, Heath depts offering secure, opt-in based short code texting for social services. This is an extremely important topic and I hope this comment thread chimes in. As leaders in mhealth dialogue, It’s incumbent upon us to make sure the flow of information is both accurate and universally accessible.

  24. Susannah -

    Thanks to the advice of your experts, I now believe there is hope for use of SMS in healthcare. At the same time, I believe this technology continues to be under utilized? Low adoption is due to lack of services, not lack of interest from patients. Hopefully, this conversation and the advice of your contributing experts will encourage development of additional services and increased value of SMS for patients.

    Perhaps the most important advice offered my multiple contributors is that successful use of SMS depends on how it’s used, not use of the technology itself.
    Currently, general fitness and nutrition dominate use of SMS in healthcare. However, many believe communication between healthcare professionals and patients to be of higher value. Context, content and volume is important. Messages should be tailored for the population, condition and demographic, personalized, relevant, even creative to sustain interest over time. Content to engage and motivate patients to act is desirable. Finally, potential needs of non-responders may be prudent.

    Two lingering questions remain and I would be grateful to your experts for their thoughts:

    1. Are concerns about rare privacy breaches and SMS associate double opt-in requirements a barrier to usage and increased value in healthcare?

    2. The new federal emergency and Amber alerts are opt-out programs. Should physicians be allowed to send 2 opt-out messages per year to their patients when preventive or care interventions are needed?

    Thanks

    -richard

  25. Esteemed Colleagues,

    Please put your regulatory reflexes and spam barometers away for a few minutes.

    Are we serious about health care? Prevention? Engagement? What better way than allowing doctors to text message alerts and reminders to “their patients” twice a year. Implied consent by choosing or seeing a doctor and allow patients to easily opt-out – (no barriers such as written consent or double opt-in).

    Concept is theoretical. I’d be grateful for your comments. Please avoid referencing obstructive FCC, HIPAA or CTIA regulations.

    Richard

  26. I realize this is an older post, but ExperiaHealth recently held an xLab (a combination learning lab and design lab) around pre-arrival communication. We invited experienced patients from area hospitals to join us and one of the number one opportunities they identified to enhance communication ahead of scheduled procedures and surgeries was just-in-time communication. As one put it, “Don’t call me two days before to remind me of something I need to do the next day.” They all agreed that texts would be a great solution.

    • The conversation is never over! I hope people continue to post examples — and questions, like the comment right above yours.

  27. Late to the game here (thanks for the invite, Susannah!) and I haven’t had the chance to read through all the responses yet, but I’m particularly excited about the possible uses of texting to reach adolescents and young adults, particularly in the area of sexual health. I know this is being used to increasing degrees all over, and I liked this article looking at a few uses of this in the NY Times:

    http://www.nytimes.com/2011/12/31/us/sex-education-for-teenagers-online-and-in-texts.html?_r=1&

    -LB

    • In general I’m not a fan of prospective survey questions since it can be hard for respondents to imagine a future with, let’s say, secure & truly useful EMR systems since so few have access to one.

      However, I really like the way this survey was done. First, they didn’t just focus on health care. Second, they asked about activities that already happen over the phone or via reminder postcards but would be better via email or text message.

      Thanks, Richard! And well done, Jonah Comstock for writing the story.

  28. Today’s episode of How Text Messaging Can Heal Health Care includes:

    The Mobile Phone: Rwanda’s Key Weapon in Making Maternal Deaths History

    Also: I started a new thread about text messaging here if you’d like to join in: Mobile, social, health, care.

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