Bidirectional Text Messaging to Improve Adherence to Recommended Lipid Testing
==============================================================================

* Laura-Mae Baldwin
* Caitlin Morrison
* Jonathan Griffin
* Nick Anderson
* Kelly Edwards
* Jeff Green
* Cleary Waldren
* William Reiter

## Abstract

*Background:* Synergies between technology and health care in the United States are accelerating, increasing opportunities to leverage these technologies to improve patient care.

*Methods:* This study was a collaboration between an academic study team, a rural primary care clinic, and a local nonprofit informatics company developing tools to improve patient care through population management. Our team created a text messaging management tool, then developed methods for and tested the feasibility of bidirectional text messaging to remind eligible patients about the need for lipid testing. We measured patient response to the text messages, then interviewed 8 patients to explore their text messaging experience.

*Results:* Of the 129 patients the clinic was able to contact by phone, 29.4% had no cell phone or text-messaging capabilities. An additional 20% refused to participate. Two thirds of the 28 patients who participated in the text messaging intervention (67.9%) responded to at least 1 of the up to 3 messages. Seven of 8 interviewed patients had a positive text-messaging experience.

*Conclusions:* Bidirectional text messaging is a feasible and largely acceptable form of communication for test reminders that has the potential to reach large numbers of patients in clinical care.

*   Adherence
*   Health Information Technology
*   Patient Engagement
*   Quality Improvement
*   Rural Health

Synergy between technology and health care in the United States is accelerating. The proportion of office-based physicians using certified electronic health records (EHRs) was 77.9% in 2015.1 EHRs have created opportunities to identify patients with health care gaps, and to monitor health care in new ways, especially since patients are simultaneously adopting personal technologies with communication and health applications.

Roughly 92% of adults own cellular phones,2 and 80% of cellular phone owners use text messaging.3 Patients seem willing to provide health information via text messaging, although this has been best studied in chronic illness management.4⇓⇓⇓⇓–9 Systematic reviews examining mobile phone messaging reminders for health care in general,10 for attendance at health care appointments,11 for facilitating self management of long-term illnesses,12 and for promoting preventive health care,13,14 have suggested benefits, but scarce literature exists about bidirectional text messaging to improve testing adherence, especially in rural areas.

This project assessed the feasibility and patient experience of using 2-way text messaging to improve adherence to recommended lipid testing.

## Methods

### Design

This mixed-methods study developed methods for and tested the feasibility of bidirectional text messaging within a primary care clinic, then interviewed patients to explore their text messaging experience. The University of Washington Human Subjects Division and the Ethics and Corporate Compliance Committee of the project's clinical partner approved the study.

### Setting

The study clinic, located in a rural Montana city, had 2 participating family physicians. The collaborating practice helped develop the text messaging intervention. One of the clinic's family physicians chose the testing topic—lipid testing for high-risk conditions (diabetes mellitus, ischemic vascular disease, coronary artery disease, or hyperlipidemia).

### Text Messaging Infrastructure

The clinic had a Business Associate Agreement with Northwest EHR Collaborative (NWEHR), a Montana-based nonprofit informatics company developing tools to improve clinics' management of the health of their patient populations. NWEHR developed a system to conduct and track the text messaging intervention15 that included a Research Electronic Data Capture (REDCap) study management component,16 a text messaging gateway using the commercial third-party Twilio system, and an intermediary message brokerage system that queried, delivered, and monitored messages between Twilio and REDCap. The study management system was accessible only to agents of NWEHR. It received a baseline data feed of patient status, then monthly updated data feeds to identify eligible patients when the text messages were scheduled. Messages to patients were limited to the standard SMS 160-character limit. Message responses from patients were monitored by staff. At the trial's conclusion, data were deidentified and exported to the researchers.

### Identification of Eligible Patients

The clinic's information technology staff used EHR data to identify all the study physicians' patients ages 18 to 75 years with at least 1 face-to-face visit with a medical provider in the practice in the previous 12 months, and who needed a low-density lipoprotein cholesterol (LDL) test based on recommendations at the time of the study.

### Patient Text Messaging Capabilities and Willingness

Clinic representatives attempted to call the 248 eligible patients and notify them that their primary care physician was participating in a project sending text messages to patients to remind them about cholesterol testing. Of the 248 eligible patients (Figure 1), 112 were not reached after 3 calls, and 7 of those reached were no longer clinic patients. Of the remaining 129, 29 (29.4%) either had no cell phone or no text messaging, and 26 (20.2%) refused participation. The clinic representative verified the cellular phone number of the 65 willing and eligible individuals. These 65 individuals were more likely to be privately insured (67.7% vs 53.6%; *P* = .048) and under 55 years (47.7% vs 33.9%; *P* = .048) than the 183 who were not. Four of the 65 had LDL testing in the roughly 4 weeks before the text message program launch, and were excluded. The 61 patients were randomly assigned to receive the text messages (n = 31) or not (n = 30) as part of a feasibility clinical trial (not reported here). After the first text message, 1 individual asked to no longer receive text messages; 2 couples (both members of the couples were in the study) had duplicate cellular phone numbers; and 1 patient was mistakenly assigned a duplicate wrong cellular phone number.

![Figure 1.](http://www.jabfm.org/https://www.jabfm.org/content/jabfp/30/5/608/F1.medium.gif)

[Figure 1.](http://www.jabfm.org/content/30/5/608/F1)

Figure 1. 
Patient identification and recruitment flow diagram.

### Text Messaging Intervention

The intervention involved 3 text messages 4 weeks apart, reminding individuals to come to the clinic laboratory: “You are due for a cholesterol test. Reply 1 for YES, I will go to <clinic name's> lab this week, open 7:30 to 6 M-F. Reply 2 for NO. Fasting not needed.” Patients who came for LDL testing received no further text messages. The study team measured patient response within 48 hours to each text message.

### Patient Interviews

One week after the second text message reminder, all 28 text messaging group members received a text message invitation: “<Clinic name> wants your ideas about its text message system. Reply 1 for YES, call me for a 10 minutes research interview ($10 paid for interview). Reply 2 for NO.” Three persons responded; 2 agreed to participate. A clinic physician called the remaining 25 individuals; 9 agreed to participate. Eight of the 11 who agreed completed the interview. An interview guide combined closed- and open-ended questions to assess patient experiences with the text message reminders (Appendix).

A University of Washington research scientist conducted the telephone interviews, documenting with handwritten notes. Frequencies of closed-ended responses were calculated, and 2 research team members (CM, LMB) conducted a simple descriptive content analysis of open-ended responses.

## Results

Two thirds of the text messaging group (19/28, 67.9%) responded to at least 1 of the up to 3 text messages. In the first month, 53.6% of the 28 patients responded by text (Table 1). This decreased to roughly a third of patients in the second and third months. Patients who responded usually answered yes or no, as requested. In a few cases, the respondents' text message tried to communicate other information to their physician (eg, “I also need to get a PSA test…”).

View this table:
[Table 1.](http://www.jabfm.org/content/30/5/608/T1)

Table 1. 
Text Message Responses by Month Message Was Sent

Of the 8 interview respondents, 5 were 55 or older; 4 were employed, 3 retired, 1 a homemaker. All 8 had attended some college; all had insurance. Seven had a positive experience with the text messages, even though only half preferred text messaging as a communication method. Five did not come in for LDL testing (Table 2); of these, 4 did not think they were due for the test. Six had concerns about maintaining personal health information privacy in text messages.

View this table:
[Table 2.](http://www.jabfm.org/content/30/5/608/T2)

Table 2. 
Patient Interview Results

## Discussion

Most individuals participating in the text message program responded to the messages and sent interpretable responses, consistent with results in other literature.5,17,18 Because text messaging is a powerful communication tool, it is not surprising that several patients communicated information beyond that requested. Because clinics may have limited staff to respond to patient text messages, clinics adopting a text-based intervention must be clear about what return communications patients can expect, if any.

In this study, clinic representatives first called patients to ascertain their willingness to receive text messages, and to verify their cellular phone numbers. Many patients were not reached, possibly because the calls were not always made by a clinic representative known to the patient. To succeed in clinical practice, approval for text message reminders would best be integrated into clinic workflow (eg, at registration). Since nearly half of the patients reached agreed to receive text messages, text message reminders could reach a significant proportion of a clinic's patient population.

This study's interviews suggested that text messaging is an acceptable form of communication between consenting patients and clinics. However, most patients expressed concerns about health information privacy. Literature in this area is sparse,19 and learning more about what patients are comfortable sending and receiving by text messaging is important. Some patients preferred other modes of communication, consistent with literature that has given patients a choice of remote communication methods.19⇓⇓⇓–23 Thus, clinics may wish to ask patients about their preferred communication methods, and offer multiple options to provide patient-centered communications.

This feasibility study recruited from the practices of only 2 physicians, limiting its generalizability. The small number of interviews limits the reliability of these findings. We were unable to determine whether individuals received tests at locations other than the participating clinic. Because elders use cellular phones and texting less often, we only included adults under 75 years.

Implementing clinical care guidelines is challenging, especially in rural settings where many patients travel longer distances for care.24 Only about half of adult and pediatric patients nationally receive indicated care.25,26 This feasibility study suggests that text messaging is a viable and largely acceptable form of communication for test reminders. The study team worked collaboratively with a community-based practice to develop a sustainable, generalizable reminder system that can function efficiently in a small to medium-sized clinic serving a rural population. A full-scale randomized clinical trial is needed to study implementation of workflow processes that identify patients willing to receive text message reminders, and to examine and compare the impact and cost effectiveness of sending reminders in different doses on medical monitoring such as laboratory tests.

## Acknowledgments

The authors thank Chris Miller for his work in identifying eligible patients and providing baseline data and monthly updates from electronic health records; Brenda Benefiet, Mitchell Marrujo, and Anthony Beaver for contacting patients regarding their willingness to be part of this text messaging program; and Lalitha Ramesh for helping develop the data capture and management system.

## Appendix

#### Improving Clinical Preventive Care Using Bidirectional Text Messaging: Interview Guide

<Clinic Name> is trying to find ways that help people get the health care they need.

XX weeks ago, <Clinic Name> sent you a text message with a reminder to get a cholesterol test.

1. Do you remember getting this text message? YES NO

IF YES:

1a. What did you think about getting a reminder like this via text message?

1.a.i. Follow-up questions:

Why was it a positive experience for you?

Why was it a negative experience for you?

**If the person does not indicate the type of experience:**

Was it a positive or negative experience for you? Depending on the answer, go back to 1.a.i.

1.a.ii. Did you get the cholesterol test? YES NO

**If NO**, why not?

**If NO**:

1.b. Have you gone in for a cholesterol test in the last XX weeks? YES NO

**If YES**, what prompted you to get it?

1.c. What do you think about using text messaging to get a reminder from <Clinic Name> for a cholesterol test?

1.c.i. Follow-up questions:

Why would it be a positive experience for you?

Why would it be a negative experience for you?

If the person does not indicate the type of experience:

Would it be a positive or negative experience for you? Depending on the answer, go back to 1.c.i.

2. There are many ways to get health reminders like this: phone, text message, postal mail, e-mail. What do you think about getting a health reminder via text message compared with these other ways?

**Prompt**: Why do they think what they think?

3. How concerned are you, if at all, about the privacy of your health information in SMS messages?

To help us understand the answers we get in this study, we'd like to understand a few things about you:

4. What is your age?

5. Currently, are you working at a job? YES NO

**If YES**, how much time?

1.  Full time

2.  Part time

3.  Not employed

4.  Retired

5.  Homemaker

6.  A student

7.  Refused

6. What is the last grade of school you have completed?

1.  Eighth grade or less

2.  Some high school

3.  Graduated high school

4.  Some college/associates degree

5.  Graduated college

6.  Post graduate

7.  Refused

7. What type of insurance do you have?

Types would be: 

1.  Private Insurance

2.  CHAMPUS (military insurance)

3.  Medicare

4.  Medicaid

5.  No insurance

6.  Other: \_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\__\_|\_

## Notes

*   This article was externally peer reviewed.

*   *Funding:* This research was funded by the Office of the National Coordinator for Health Information Technology under award number 10775336, the Northwest EHR Collaborative, and the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000423. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Office of the National Coordinator for Health Information Technology or the National Institutes of Health.

*   *Conflict of interest:* none declared.

*   To see this article online, please go to: [http://jabfm.org/content/30/5/608.full](http://jabfm.org/content/30/5/608.full).

*   Received for publication February 28, 2017.
*   Revision received May 22, 2017.
*   Accepted for publication May 31, 2017.

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